Not an online form: this form must be printed out, completed by hand, and posted to the County Council (address at the bottom of final page).
Data Protection: The information given in this form will be recorded on a computer system subject to the provisions of the Data Protection Act 1998 and may be used for data matching purposes for the detection and prevention of fraud and retained for 12 months. The accompanying personal evidence will be destroyed as soon as your application has been processed. Telephone numbers are requested as we may need to contact you about your application or if you lose your pass and it is returned.
Please tick one box only
I do not currently have any type of concessionary travel pass
I am a current Hampshire County Council holder wanting to change concession (no charge). Please return current pass
I am a current Hampshire County Council holder wanting a replacement due to a lost, damaged or stolen pass.
Note: A £10 fee will apply unless accompanied by an official crime number. In case of theft complete Part Two and then go straight to Part Seven to sign and date - no photo is required.
Crime Number (if applicable): _________________
Date of birth
National Insurance number
Please tick all that apply
Blind or partially sighted
Profoundly or severely deaf
Disability or injury which has a substantial and long term effect on my ability to walk
Without arms or the long term loss of the use of both arms
Severe learning difficulty
Prevented from holding or would be refused a driving licence on medical grounds
Member/Veteran of the Armed Services seriously injured in service
Type of concession required
Please tick one
A disabled person’s bus pass, or
A disabled person's companion bus pass, or
A disabled person’s vouchers
Evidence of eligibility
Proof of each of the following are required before your application can be processed (please only send copies and not originals).
Also if you are applying for a companion pass a health care letter is required
Plus ONE only of the following (tick or fill in as necessary):
Data Protection Act 1998
If you have been previously assessed regarding your mobility, please tick if you consent to the access of your Blue Badge records to assist with making better informed decisions and also speeding up the application process for your travel concession.
Hampshire County Council Blue Badge.
Please provide the card number:__________________
Award letter for any Attendance Allowance
Award letter for the Higher Rate Mobility Component of Disability Living Allowance
Award letter for a War Pensioners Mobility Allowance
Award letter for guaranteed income payment for tariff levels 1- 8 under the 2005 Armed Forces Compensation Scheme
Letter from the DVLA giving notice of long-term refusal or withdrawal of driving licence on medical grounds (misuse of alcohol or drugs are not included under this scheme)
Award letter for personal independence payment (PIP) where the applicant has been awarded at least 8 points or more for the PIP "Moving Around" or "Communicating Verbally" activities
(for a companion pass only) Original disability evidence PLUS a letter from a health care professional supporting the application
Colour passport photograph
Please ensure that you enclose a recent colour passport-sized photograph for use on your bus pass or on each voucher. Please clearly write your name and date of birth on the reverse of your photograph.
I confirm that I am a permanent resident in Hampshire and can only have one concession for my sole use to which I am entitled under the Transport Act 2000 and subsequent amendments. I understand that the concession is not transferable and that misuse may result in prosecution. I authorise Hampshire County Council to make any enquiries necessary to verify entitlement for travel concessions. The information given is correct to the best of my knowledge and belief. Applicants under the age of 16 will need a parent/guardian to sign the form.
Please send your application form, photograph, and copies of evidence to:
P O Box 696
Telephone: 0300 555 1376*
Textphone: 0300 555 1390*
*Calls to 0300 numbers are included in call packages, or charged at the same rate as 01 and 02 numbers. Costs may vary depending on your telecoms provider and whether you are calling from a landline or mobile. Further information about call charges can be found at www.ofcom.org.uk