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Application for registration
as a disabled person
The Chronically Sick and Disabled Persons Act 1970
To complete this form, please click into the fields. You can save at any time as you work on it. Please email
it to access@oxfordshire.gov.uk or print it and post it to the Access Team, PO Box 780, Oxford OX1 9GX.
TitleName
Address
Phone number(s)
Date of birthGender
Nature of
disability
GP's name and address,
GP's phone number
Ethnic origin. Please select from dropdown list
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I am receiving the Mobility Component
of Disability Living Allowance. (* Please supply evidence)
I am receiving the War Pensions Mobility Supplement.
(* Please supply evidence)
I am receiving other benefits (please give details)
Please sign the declaration below:
I confirm that I am a permanent resident of Oxfordshire and that the information I have provided in this
form is accurate. I understand that the information will be recorded and retained by the county council
while I remain on the register, and will be used only to support my application for registration. I confirm
that I am happy for the council to contact my GP in order to discuss my application.
Signed Date
* Please note, if you are emailing your application form, you will need to attach your evidence.
