Forms home Mobility card application form I am completing this form(Required) For myself On behalf of someone else Assessing your eligibilityApplicants may qualify for a Mobility Card if they meet one of the following and provide documentary evidence.Please select which apply to you(Required) 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 select which apply to the applicant(Required) 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) Contact number(Required)Email(Required) Relationship to applicant(Required) For all remaining questions please answer on behalf of the applicant Applicant detailsTitle(Required) First name(Required) Last name(Required) Date of birth(Required) Day Month Year AddressFind addressSelected address Contact number(Required)Email(Required) Proof of identityPlease 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 Select files Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 10 MB, Max. files: 2. Proof of residencePlease 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 Select files Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 10 MB, Max. files: 2. Additional supporting documentsPlease 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 Select files Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 10 MB, Max. files: 2. 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 Select files Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 10 MB, Max. files: 2. 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 Select files Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 10 MB, Max. files: 2. PhotographPlease upload a photograph of yourself for your card(Required) Drop files here or Select files Accepted file types: jpg, jpeg, png, Max. file size: 10 MB, Max. files: 1. Photo guidance: Please provide a head and shoulders shot taken in front of a plain background. Your health and disabilityWhat are your health and disability difficulties and how long have you had them?(Required)Medical name of your disabilityLength of time of disability Please explain how your disability affects your ability to use public transport(Required)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?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 Select files Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 10 MB, Max. files: 2. Transport servicesWhich 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 number(Required) Issuing Authority(Required) Date of expiry(Required) Day Month Year 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 outsideAre 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)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)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 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 communicationPlease 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 name Interpreter's address Street Address Address Line 2 City AberdeenshireAngus/ForfarshireArgyllshireAyrshireBanffshireBedfordshireBerkshireBerwickshireBlaenau GwentBridgendBuckinghamshireButeshireCaerphillyCaithnessCambridgeshireCardiffCarmarthenshireCeredigionCheshireClackmannanshireConwyCornwallCromartyshireCumberlandDenbighshireDerbyshireDevonDorsetDumfriesshireDunbartonshire/DumbartonshireDurhamEast Lothian/HaddingtonshireEssexFifeFlintshireGloucestershireGwyneddHampshireHerefordshireHertfordshireHuntingdonshireInverness-shireIsle of AngleseyKentKincardineshireKinross-shireKirkcudbrightshireLanarkshireLancashireLeicestershireLincolnshireLondonMerthyr TydfilMiddlesexMidlothian/EdinburghshireMonmouthshireMorayshireNairnshireNeath Port TalbotNewportNorfolkNorthamptonshireNorthumberlandNottinghamshireOrkneyOxfordshirePeeblesshirePembrokeshirePerthshirePowysRenfrewshireRhondda Cynon TaffRoss-shireRoxburghshireRutlandSelkirkshireShetlandShropshireSomersetStaffordshireStirlingshireSuffolkSurreySussexSutherlandSwanseaTorfaenVale of GlamorganWarwickshireWest Lothian/LinlithgowshireWestmorlandWigtownshireWiltshireWorcestershireWrexhamYorkshire County Postcode Interpreter's relationship to applicant Do you need to receive information in large text format? Yes No Declaration of consentBy 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 cardDeclaration(Required) I agree Summary{all_fields}
