Disabled Persons Parking Scheme New Application Form for

Disabled Persons Parking Scheme
New Application Form for Individuals
Section A: To be completed by the applicant or agent
Surname
Given Name/s
Date of Birth
Address
Postal Address (if different)
Phone
Is the permit for a driver or
passenger? (please tick)
For Driver
Driver
Passenger
Driver Licence No.:
Expiry Date:
What is your disability?
What appliance do you use as
an aid?
Declaration by Applicant
I make this declaration in the firm belief that all the information provided on this form is, to the best of
my knowledge, true and correct and I am aware that false declarations may be punishable by law.
I will fully comply with the conditions of use for this permit.
If my circumstances change in any way likely to affect my eligibility for the permit, I agree to notify the
issuing authority within fourteen (14) days. I further agree that the permit remains the property of the
issuing authority and will be returned within seven (7) days of notification of such return being required.
Applicants Signature (or agent): ________________________ Date: ________________
Privacy Notification: The personal information provided on this form will be used by Wellington Shire Council for the
purpose of maintaining our Disabled Persons Parking Scheme register. The personal information will be used solely by
Council for that primary purpose or directly related purposes.
Label No.
OFFICE USE ONLY
Date of Issue
Expiry Date
Label Colour
Category of Label
Issuing
Section B: To be completed by a Medical Practitioner
Note: The information on this form will be used by Council staff to determine the
eligibility of your patient for a disabled persons parking label. A permit will not be
issued unless all details on this application form are completed
1
What is your patient’s disability?
2
Does the disability require the continual use of
an aid?
3
What type of aid does your patient use?
4
Is the significant disability permanent?
5
If the disability is not permanent how long is it
likely to last? (In Months)
YES
NO
YES
NO
NOTE: A permit is unable to be issued for a disability lasting
less than 6 months
6
Does your patient’s disability result in extreme
danger to themselves or others in a public place
without continuous help of a caregiver?
YES
NO
7
Does your patient’s disability affect their
capacity to walk distances without regular rest
breaks?
YES
NO
8
Does your patient have an ACUTE or CHRONIC
illness which would affect their ability to walk
any distances and may affect their health
acutely or in the long term?
YES
NO
If yes, please provide supporting information
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Signature of Practitioner
Date
Please Print Name
Qualifications
Address
Phone