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

Applicant Information

Full Name *

Email Address *

Faculty/Department *

Staff Number *

Contact Telephone Number *

Home Campus *

• Belfast
• Coleraine
• Jordanstown
• Magee

Please indicate one of the following *

• Option 1 - A recommendation for a temporary car parking permit has been provided by the Occupational Health Department as part of the University’s ‘Return to Work’/ referral process.
• Option 2 - I require a referral to a health professional for an independent assessment.(A member of the Car Parking Team will be in touch to arrange an appointment for you)

Line Manager/Head of School/Department Name This is required if you have selected Option 1 above.

Line Manager/Head of School/Department Email This is required if you have selected Option 1 above.

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