Seven Company Vehicle Drivers Form

Company Vehicle Drivers Form

Name *

First

Last

Permanent Home Address *

Address Line 1

Address Line 2

City

State / Province / Region

Driving Licence Number *

Date Passed Test

Date of Birth

Age *

Has your Licence been suspended for any reason within the last 10 years? If yes, please state date suspended and duration *

Have you currently seven or more penalty points on your licence? *

Have you been convicted during the past five years of (or is any prosecution pending for) any motoring offence involving drink or drugs (offence code DR) reckless or dangerous driving (offence code DD), failing to stop or report an accident (offence code AC)? If yes, please state offence code. *

Do you currently suffer from any medical conditions, illness or disability that could affect your ability to drive safely? i.e. heart complaint, sleep apnoea, epilepsy or diabetes? If yes, please give details. *

Do you suffer from any sudden attacks or disabling giddiness, fainting or blackouts? *

Do you suffer from defective hearing (which is not corrected by wearing a suitable aid)? *

Do you suffer from defective eyesight (which is not corrected by wearing glasses or contact lenses)? *

Have you ever had a motor policy cancelled, a proposal declined or a renewal refused by an insurer? *

Acknowledgement

PLEASE NOTE: You are obliged to advise the company of any change in circumstances with regards to your fitness to drive, fixed penalty notices or convictions or prosecutions which may occur after completion of this form.

I acknowledge that the provided information is correct and up to date *

Signature of the proposed Company Vehicle Driver: *

Clear Signature

Date Completed *

Company Vehicle Drivers Form

Acknowledgement

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