ࡱ> []Zg 0 bjbjJJ X(ub(ub4D D 8 $0#\\\J#L#L#L#L#L#L#$%q(p#\::"\\p#n#   \jJ# \J#  Z!!H/ ωr!6##0#z!,[)Z[)![)!\\ \\\\\p#p# \\\#\\\\[)\\\\\\\\\D B : Car Parking Permit Application Declaration of status NameDepartmentLocation you are basedPosition Application Number1 Does your current condition affect your mobility? If yes please answer question 2Yes(No(2If your mobility is affected, how far are you able to walk? 0 150 metres(150 300 metres(Upto 500 metres(Please provide any additional information which might be useful e.g Terrain 3Does your condition affect your ability to travel via public transport? Yes(No(4Please state the length of time which you anticipate you will be affected by this condition:0 6 months (6 12 months (12 months plus (5How is your journey to work affected by your condition? *We are NOT seeking specific clinical information, only how your condition affecte your journey6Please provide any other information you believe is relevant to your application:Please sign this declaration to confirm the information is true and accurate. Please note the information provided in this declaration will inform any decision in relation to your University car parking permit application. Any false declaration will be considered misconduct and may result in disciplinary action being instigated against you. 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