LMUSU Driver Disclosure Form

Leeds Beckett University Driver Disclosure Form for Use of Hire Vehicles

Please complete this form with reference to your Driver’s Licence and take a copy of it to the Student Sport Office. You will also need to print a copy of your electronic counterpart from the DVLA website. Both parts will be needed to get clearance to use any transport hired by the University

Name of Driver ……………………………………………………

National Insurance No ………………………………………….

Driver’s Licence No. …………………………………………….

Home Address (on licence) …………………………………… ……………………………….

………………………………. Driver details

Date of birth Date passed test Type of licence Driving Experience (No of Years, HGV etc) Full (UK) Foreign Driver eligibility Category of vehicles entitled to drive …………………………………..

Please answer the following questions and give full details where appropriate 1. Do you have any physical or mental disabilities, or suffer from diabetes, epilepsy or any heart complaint? YES / NO If YES please give details of disability, medication taken and if DVLA are aware and what restrictions have been imposed. …………………………………………………………………………………………… ……………………………………………………………………………………… 2. Have you had any motor accidents or made any claims (including theft) in the last 3 years? YES / NO

Date Circumstances Costs Costs NCD Own 3rd party affected

D:\Docs\2018-04-06\0ed1f96c1204a67da386ad0fe2fcd7e3.doc 3. Have you had (or have pending) any convictions in connection with a motor vehicle in the last 5 years? YES / NO

Date Conviction Code Circumstances Period Disqualified Fine

4. Has any Insurance company or underwriter, refused you insurance or imposed any special terms? YES / NO If YES please give details …………………………………………………………………………………………… ……………………………………………………………………………………………

For completion at the Student Sport Office

I declare that the above particulars are true and correct and that no material information which would affect the insurer’s assessment or acceptance of this risk has been withheld. I agree to be responsible for the vehicle as a ‘volunteer’ driver. I have read and agree to adhere to the Student Sport Office Driver Guidelines. I agree that the University may check my license details with the DVLA in order to use University Insured vehicles.

Driver’s Signature …………………………………………………………………

Date …………………..

Driver’s Mobile Telephone Number …………………………….

Date Driver’s Licence checked at Student Sport Office

………………………………

Authorisation to drive Hired University Transport

Minibus (15 seats) Minibus (12 seats) MPV Car Van

Signed by ………………………………..

Position …………………………………..

Date ……………………………………….

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