Driver Application Form

Title:
Fullname:
Age last birthday:
Date of birth:
Full postal address:
Postcode:
Email address (mandatory):
Do you hold a full current motor vehicle licence:
Give date test passed and where:
Are you a permanent UK resident:
Are you/have you been insured in respect of any motor vehicle:
If ‘yes’ please state:  
Name of Insurer:
Policy number:
Date of expiry of policy:
Have you:  
Been convicted of any offence in connection with a motor vehicle or motorcycle (other than parking) or is any prosecution pending?
If ‘yes’ whom and for what offences and with what results?
Been disqualified from holding or obtaining a driving licence:
If ‘yes’ give full details:  
Reason for disqualification:
Date of disqualification:
Date of removal of disqualification:
Have you ever:  
Had a proposal for any motor or motorcycle insurance declined, had a policy cancelled or has renewal of a policy refused?
Been required to carry the first portion of any loss, had a premium increased or had special conditioning imposed?
If either question is answered ‘yes’ give details:
Do you suffer from defective vision or hearing or from fits or any physical infirmity?
If ‘yes’ give full details:
Have there been any accidents or losses during the past 3 years?
If ‘yes’ give details (damage including fire and/or theft to vehicle(s) being driven by driver completing this form):
To be completed by each staff member required to drive company vehicles. Please attach a photocopy of your driving licence for retention by Head Office (if photo card please copy counterpart driving licence as well)

In signing this form, candidates are declaring that the above answers are true and correct in every respect:
Electronic Signature (please state name):
Date: