---

This form is for staff including associate staff members and contract services staff, who have a long term health condition and mobility difficulty. Please complete details below.

Applicant Information

Full Name *

Email Address *

Faculty/Department *

Staff Number *

Contact Telephone Number *

Home Campus *

• Belfast
• Coleraine
• Jordanstown
• Magee

A referral to an appointed health professional will be arranged for an independent assessment and a member of the Estates Services car parking team will be in touch to arrange an appointment.

---