Privately Owned

Application Type *

Your Name *

Email Address *

Contact Number *

Name of Disabled Person (if different to previous)

Contact Number (if different to previous)

Vehicle Registration Number *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Date of birth *//

I understand the exemption may only be used whilst the disabled person is in the car. *

Photocopy of your PIP /Entitlement Summary with current year's date *

Click or drag a file to this area to upload.

Copy of Vehicle Registration Document (V5) – Showing vehicle taxation class disabled *

Click or drag a file to this area to upload.

Message (Optional)

Privacy Notice *

I have read the Privacy Policy and understand how my data will be used and processed.

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