Training Forum

 

Name:                                                                                                 

 

Address:                                                                                              

 

                                                                                                           

 

Age:                                                                                                    

 

Occupation:                                                                                         

 

Length of driving experience on a full Licence:               Years                     Months               

 

Have you :-

 

a)         Been convicted of any motoring offence or is any prosecution

            pending?                                                                                               YES/NO

 

b)         Any abnormal medical condition, physical infirmity or defects?               YES/NO

 

c)         Defective vision or hearing?  (The wearing of spectacles need

            not be disclosed).                                                                                 YES/NO

 

d)         Been refused motor insurance, renewal or had your policy

            cancelled or had any special terms or conditions or higher

            excess imposed by Insurers?                                                                 YES/NO

 

e)         Been involved in a motor accident in the past 3 years?                           YES/NO

 

            If the answer to any of the above question is Yes, please give details overleaf.

 

I DECLARE THAT THE INFORMATION GIVEN IS TRUE AND CORRECT AND THAT I WILL NOTIFY ANY CHANGE.

 

Date:                                                                      Signed:                                                  

 

Signed:(Tutor)                                                       

 

Date: