Step 1 of 5 20% PERSONAL DETAILS - Just a few questions about you. Name* MrMrsMissMsDrProf.Rev. Title First Last Address* Street Address Address Line 2 City County Postcode Home PhoneMobile Phone*Email Address Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 DRIVING DETAILS - To be completed by any volunteers wanting to drive. Driving Licence Number*Driving Licence valid fromMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Driving Licence valid to*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920How many years have you held your driving license?*Do you have any endorsements?*YesNoIf yes, please give details,Do you have any convictions for motor vehicle offences in the last 5 years?*YesNoIf yes, please give details,Have you ever been refused motor vehicle insurance?*YesNoIf yes, please give details,Have you as a driver been involved in an accident in the last 5 years?*YesNoIf yes, please give details,Please give details of any relivent driving experince and/or additional licenses such as HGV PSV. GENERAL HEATH - Please give details of any health conditions that may affect your ability to drive safely. Have you ever been diagnosed with any of the following? Epilepsy Diabetes Heart disease A mental health condition High blood pressure Visual disorders If yes, please give detailsDo you have any other health issues that may affect your ability to drive? REFERENCES – in the interest of some of the groups of people you may be asked to drive for, please supply the name and address of 2 referees who are not closely related to you and are over the age of 18. Reference 1 - Name* MrMrsMissMsDrProf.Rev. Prefix First Last Address* Street Address Address Line 2 City County Postcode Phone number*Section BreakReference 2 - Name* MrMrsMissMsDrProf.Rev. Prefix First Last Address* Street Address Address Line 2 City County Postcode Phone number* DECLARATION. Please read the below declaration carefully and tick the box to confirm that you have read and agree to the below terms and conditions. i) I declare that all the details given on this form are correct to the best of my knowledge. I agree to exercise all duty of care for the safety of the passengers and the security of the vehicle whilst in my care. ii) I understand that it is an offence under the Road Traffic Act to knowingly make a false statement to obtain insurance cover. iii) I undertake to inform the CEO of Community Link of any subsequent illness, conditions or events which might affect my ability to drive or assist in a minibus. iv) I further undertake to report any subsequent refusal of motor insurance or driving convictions. I understand the failure to do so and any false declaration above may render the insurance cover for the vehicle invalid and that I may become responsible for all costs and damages. v) I also undertake to notify the organisation of any accident that occurs whilst I am responsible for any of the organisation vehicles. vi) I understand that all the information given to Community Link will be treated in confidence and that any stored data or information will be covered by the Data Protection Act. I have read and agree with the above declaration.* I Agree CAPTCHA
