Mobility card application form – WordPress on Azure

I am completing this form(Required)

For myself

On behalf of someone else

Applicants may qualify for a Mobility Card if they meet one of the following criteria and provide documentary evidence.

Please tell us what makes you eligible for a Mobility Card?(Required)

Select what applies to you

Severe difficulty in walking and unable to use public transport without assistance or permanent wheelchair user

Registered blind

In receipt of the Disability Living Allowance - higher rate of the mobility component

In receipt of War Pensioner's mobility allowance

In receipt of Personal Independence Payments - 8 points or more in moving around

Please tell us what makes the applicant eligible for a Mobility Card?(Required)

Select what applies to the applicant

Severe difficulty in walking and unable to use public transport without assistance or permanent wheelchair user

Registered blind

In receipt of the Disability Living Allowance - higher rate of the mobility component

In receipt of War Pensioner's mobility allowance

In receipt of Personal Independence Payments - 8 points or more in moving around

Your details (person completing this form)

Title

First name(Required)

Last name(Required)

Relationship to applicant(Required)

Your contact details (person completing this form)

Contact number(Required)

Email(Required)

For all remaining questions please answer on behalf of the applicant

Applicant details

Title(Required)

First name(Required)

Last name(Required)

Date of birth(Required)

Day

Month

Year

Applicant contact details

Address

Find address

Contact number(Required)

Email(Required)

Proof of identity

Please upload a copy of one of the following as proof of identity:

Driving licence
Passport photo page
UK local residents' parking permit
Birth certificate (if it is the same as your current name)
Marriage certificate
Asylum registration card or standard acknowledgement letter
NHS medical card
Statutory declaration of change of name

Upload proof of identity(Required)

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 50 MB, Max. files: 2.

Proof of residence

Please upload a copy of one of the following as proof of residence:

Council or housing association rent book
Tenancy agreement
Television licence or exemption
Home content insurance document confirming current policy
benefits or pension book
Council Tax bill
Letter of entitlement of benefits or pension
Utility bill dated within 3 months
Domiciliary care bill dated within the last 3 months

Upload proof of residence(Required)

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 50 MB, Max. files: 2.

Higher rate mobility DLA proof

Please upload a copy of your certificate of entitlement or entitlement notice dated within the last 12 months.

If you cannot produce a copy of your certificate of entitlement, a replacement may be obtained from the Disability Benefits Agency at the Department of Work and Pensions.

Please upload proof of your Disability Living Allowance(Required)

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 50 MB, Max. files: 2.

War pensions mobility proof

Please upload a copy of your official letter of award.

If you cannot produce your letter of award, please get a replacement from the Veterans Agency.

Please upload proof of your War Pensions Mobility Supplement(Required)

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 50 MB, Max. files: 2.

Personal Independence Payment

Please upload a copy of your document confirming receipt of Personal Independence Payment.

Please upload proof of your Personal Independence Payment(Required)

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 50 MB, Max. files: 2.

Photograph

Please upload a photograph of yourself for your card(Required)

Photo guidance: Please provide a head and shoulders shot taken in front of a plain background.

Drop files here or

Accepted file types: jpg, jpeg, png, Max. file size: 50 MB, Max. files: 1.

Your health and disability

What are your health and disability difficulties and how long have you had them?(Required)

Medical name of your disability

Length of time of disability

Please explain how your disability affects your ability to use public transport(Required)

Your health and disability

How often is your ability to use public transport affected in this way?(Required)

All the time

Sometimes

Please tell us how often your ability is affected(Required)

Is there anything else you would like to tell us about your disability?

Your health and disability

Please upload a GP's report that includes the following information:

Confirmation of your disability or condition
How long you have had your disability condition
How long your disability or condition is likely to last
How your disability or condition adversely affects your ability to walk
Whether or not you use a walking aid
A list of your prescribed medication and a recent repeat prescription

Please note we do not:

Provide you with a separate form for your GP
Contact your GP
Accept medical certificates
Pay for medical reports
Ask your GP if they believe you qualify for a Mobility Card

Upload your GP's report(Required)

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 50 MB, Max. files: 2.

Which public transport services do you use?(Required)

Please select the services you use.

Taxicard

London Dial-a-ride

Trains

Tubes

Buses (any type)

Taxicard number(Required)

Do you have a Blue Badge?(Required)

Yes

No

Blue Badge details

Blue Badge number(Required)

Issuing Authority(Required)

Date of expiry(Required)

Day

Month

Year

Blue Badge details

Are you a driver or passenger?(Required)

Driver

Passenger

How often do you use your badge?(Required)

Daily

Three or more times a week

About once or twice a week

About once a month

Less than once a month

Getting around outside

Are you able to stand?(Required)

Yes

No

Do you have difficulty in standing?(Required)

Yes

No

How long are you able to stand?(Required)

What prevents you from standing longer?(Required)

Getting around outside

How far can you usually walk?(Required)

Can you climb steps and stairs without difficulty?(Required)

Yes

No

Please describe your difficulty in climbing steps and stairs.(Required)

Getting around outside

How long have you had these mobility difficulties?(Required)

Is there anything else you would like to tell us about your mobility difficulties?(Required)

Do you use a wheelchair(Required)

Yes

No

Details of wheelchair use

What type of wheelchair do you use?(Required)

A powered wheelchair

A manual wheelchair

Are you reliant on someone else to push you in your wheelchair?(Required)

Yes

No

Who was your wheelchair was recommended by?

How often do you use a walking frame?(Required)

Sometimes

Always

Never

How often do you use a walking stick?(Required)

Sometimes

Always

Never

How often do you use any other equipment?(Required)

Sometimes

Always

Never

What other walking equipment do you use?(Required)

Who was your walking aid recommended by?(Required)

Your preferred means of communication

Please select if any of the following apply to you:

You are hard of hearing

You are profoundly deaf

You need a sign language interpreter

You have a speech impairment

You are visually impaired

English is not your first language and you need an interpreter

What language signer do you need?(Required)

Please specify the language(Required)

Interpreter's details

Interpreter's name

Interpreter's address

Street Address Address Line 2 City County Postcode

Interpreter's relationship to applicant

Do you need to receive information in large text format?

Yes

No

Declaration/Consent

By submitting this form, you declare:

All information given is true
You will let us know if there are any changes in your mobility needs
You may be prosecuted is information given on this form is wrong or untrue or any supporting documentation is false or fraudulent.

You also authorise your healthcare professional, social services officer and any contact person nominated on this form to disclose any necessary information for the purpose of assessing my eligibility for a mobility card

Summary

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