If YES, please send current evidence of the reason, issued by the DVLA, and go to SECTION 4 Section 3 Eligibility Assessment (please provide medical evidence) – 1.Please describe your illness or disability, giving as much detail as possible (continue on a separate sheet if necessary):_______________________________________________________ 2.How long have you suffered form the disability / illness? Years Months 3.Do you regularly use a walking aid or a wheelchair? Yes No If YES, please state the type of aid(s) you use:_________________________________________ ________________________________________________________________________________ How often do you use them?______________________________________________________ 4.How far can you walk on flat ground before you feel breathless, feel pain or severe discomfort and need to rest? ______________________________ Metres 5.Roughly, how many minutes does it take you to walk this far?_____________ 6.Please give details of how your day to day activities are affected by your disabilities / Section 4 - Declarations and signatures. I declare that to the best of my knowledge all the statements I have made on this form are true and I agree to The London Borough of Brent contacting my GP/Health Professional if necessary for the purpose of obtaining information in support of my application.
If YES, please send current evidence of the reason, issued by the DVLA, and go to SECTION 4 Section 3 – Eligibility Assessment (please provide medical evidence) 1.Please describe your illness or disability, giving as much detail as possible (continue on a separate sheet if necessary):_______________________________________________________ 2.How long have you suffered form the disability / illness? Years Months 3.Do you regularly use a walking aid or a wheelchair? Yes No If YES, please state the type of aid(s) you use:_________________________________________ ________________________________________________________________________________ How often do you use them?______________________________________________________ 4.How far can you walk on flat ground before you feel breathless, feel pain or severe discomfort and need to rest? ______________________________ Metres 5.Roughly, how many minutes does it take you to walk this far?_____________ 6.Please give details of how your day to day activities are affected by your disabilities / Section 4 - Declarations and signatures. I declare that to the best of my knowledge all the statements I have made on this form are true and I agree to The London Borough of Brent contacting my GP/Health Professional if necessary for the purpose of obtaining information in support of my application.
Disabled-persons-freedom-pass-application.docx