Licensing, Public Protection, Assets & Environment

RENEWAL

B O R O U G H O F T A M W O R T H Licensing, Public Protection, Assets & Environment Application for Hackney Carriage and Private Hire Drivers License PLEASE COMPLETE ALL OF THIS FORM IN BLOCK CAPITALS WITH THE EXCEPTION OF THE SIGNATURES In accordance with the provisions of the Local Government (Miscellaneous Provisions) Act 1976 and the Town Police Clauses Act 1847 I (Full Name) ------of (address) ------

Telephone Number ------hereby make application for a license to drive a Hackney Carriage Vehicle or Private Hire Vehicle operating within the area of the Tamworth Borough Council.

THIS APPLICATION MUST BE PRESENTED IN PERSON BETWEEN THE HOURS OF 09.00 AM AND 12.00 PM (NOON) MONDAY TO FRIDAY (PLEASE NOTE POSTAL APPLICATIONS WILL NOT BE ACCEPTED)

YOUR APPLICATION CANNOT BE ACCEPTED UNLESS IT IS ACCOMPANIED BY THE APPROPRIATE FEE AND SUPPORTING DOCUMENTATION AS DETAILED IN THE APPLICANTS GUIDANCE

When submitting an application for a license to drive a hackney carriage or private hire vehicle all criminal convictions must be disclosed whether spent or otherwise in accordance with Rehabilitation of Offenders Act 1974 (exemption) Order. The information you give will be treated in confidence and will only be taken into account in relation to your application.

You should be aware that the licensing authority is empowered in law to check with the police for the existence and content of any criminal record held in the name of an applicant. Information received from the Police will be kept in strict confidence and will be retained for no longer than is necessary.

The disclosure of a criminal record or other information will not debar you from gaining a license unless the authority considers that the conviction renders you unsuitable. In making the decision the authority will consider the nature of the offence, how long ago and what age you were when it was committed and any other factors which may be relevant. Any applicant refused a drivers license has a right to appeal to a Magistrates Court.

If you would like to discuss your application you may telephone 01827 709445 or 01827 709674 for advice.

1 PART A - TO BE COMPLETED BY APPLICANT

1. NAME AND ADDRESS OF VEHICLE PROPRIETOR FOR WHOM YOU WILL DRIVE:

------

------TEL NO:------

2. NAME OF RADIO CIRCUIT COMPANY OPERATING VEHICLE (if any):------3. HAVE YOU EVER BEEN CONVICTED OF ANY MOTORING OFFENCE(S): YES/NO IF YES GIVE DETAILS

NATURE OF DATE OF COURT PENALTY OFFENCE OFFENCE PUNISHMENT POINTS

NOTE: A COMPLETE AND FULL DECLARATION OF ALL PAST MOTORING OFFENCES MUST BE MADE BUT SUCH INFORMATION WILL BE TREATED IN STRICT CONFIDENCE AND WILL NOT NECESSARILY PREJUDICE THE GRANTING OF A LICENSE.

4. ARE THERE ANY CRIMINAL OR MOTORING PROSECUTIONS PENDING AGAINST YOU: If YES please state: YES/NO a) Alleged Offence: ------

b) Date and Place of Hearing: ------(note - Applicant to declare all convictions under the Rehabilitation of Offenders Act 1974 (exemption) Order, whether spent or otherwise)

5. HAVE YOU EVER BEEN REFUSED A LICENSE OR HAS A LICENSE BEEN REVOKED BY THIS OR ANY OTHER AUTHORITY: YES/NO If YES Supply details of such refusal or revocation:

Local Authority Name: ------

Date of Refusal/Revocation: ------

Reason for Refusal/Revocation: ------

6. NATIONAL INSURANCE NUMBER: ------

7. DRIVING LICENSE NUMBER: ------NOTE: The Driving License must be produced for inspection when submitting the application. SEE NOTE 2

8. IS DRIVING A HACKNEY CARRIAGE OR PRIVATE HIRE VEHICLE TO BE YOUR ONLY EMPLOYMENT: IF NO STATE YES/NO a) Name of other employer ------

b) Address ------2 c) Nature of other employment ------

PART B

AUTHENTICATION OF APPLICATION BY PROPRIETOR/OPERATOR

I HEREBY CERTIFY THAT I HAVE EXAMINED THE ABOVE APPLICATION AND THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF THE DETAILS OF THE APPLICATION ARE CORRECT.

Signed ------VEHICLE PROPRIETOR

DECLARATION OF APPLICANT

I THE UNDERSIGNED CERTIFY THAT I AM AT THIS DATE, AND HAVE BEEN FOR THE PREVIOUS TWELVE MONTHS, THE HOLDER OF A LICENSE (NOT BEING A PROVISIONAL LICENSE) GRANTED UNDER PART III OF THE ROAD TRAFFIC ACT 1972 AUTHORISING ME TO DRIVE A MOTOR CAR AND THAT THE DETAILS I HAVE RECORDED ON THIS APPLICATION ARE CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF AND I UNDERSTAND THAT, IF I HAVE OMITTED ANY MATERIAL PARTICULAR OR KNOWINGLY STATED ANYTHING THAT IS UNTRUE THE LICENSE I MAY HAVE BEEN GRANTED MAY BE REVOKED AND I MAY BE SUBJECT TO LEGAL PROCEEDINGS FOR OBTAINING OR ATTEMPTING TO OBTAIN A LICENSE BY DECEPTION:

I AFFIRM THAT I AM AWARE THAT THE COUNCIL WILL MAKE ENQUIRIES WITH THE DRIVER AND VEHICLE LICENSING AGENCY (DVLA) REGARDING THE STATUS OF MY DRIVING LICENSE RECORD AND I GIVE CONSENT FOR THESE ENQUIRIES TO BE MADE.

Signed ------

Dated ------

Tamworth Borough Council is the data controller of this information. The information is collected on this form will only be used to assess this application and for no other purposes. The information collected on this form may be disclosed to Inland Revenue, in order to verify the information provided so to ensure the protection of public funds. Under the Data Protection Act you have the right to see your information for a set fee. For further information contact the Information Officer on 01827 709570.

PART D B O R O U G H O F T A M W O R T H Licensing, Public Protection, Assets & Environment 3 Application for Hackney Carriage and Private Hire Drivers Licence Medical Questionnaire

PLEASE COMPLETE ALL OF THIS FORM IN BLOCK CAPITALS

1. NAME OF APPLICANT: ------

2. DATE OF BIRTH: ------

3. NAME AND ADDRESS OF YOUR DOCTOR:------

4. HAVE YOU EVER HAD: a. Any Heart Condition YES/NO b. Any Epileptic Attack, Stroke, or Loss of Consciousness YES/NO c. A Problem with Alcoholism or Drug Addiction YES/NO d. Any Mental Health Issues YES/NO

5. EYESIGHT - DO YOU HAVE:

a. A good standard of sight in both eyes YES/NO b. Loss of sight in One Eye, Tunnel Vision, or any other impairment of vision YES/NO

6. HAVE YOU OR ARE YOU BEING TREATED FOR:

a. Angina YES/NO b. Diabetes YES/NO c. Mental or Nervous Disorder YES/NO

7. IF YOU ANSWERED YES TO QUESTION 4, 5 OR 6 OR IF YOU HAVE ANY OTHER MEDICAL CONDITION AFFECTING YOUR DRIVING, PLEASE GIVE PARTICULARS HERE:

------

8. ARE YOU CURRENTLY TAKING MEDICATION PRESCRIBED BY A DOCTOR: YES/NO

If YES write name of medication ------

9. DO YOU CONFIRM THAT YOU WILL NOTIFY THE COUNCIL OF ANY DISABILITIES THAT MAY ARISE IN FUTURE AFFECTING YOUR ABILITY TO PERFORM YOUR DUTIES AS A HACKNEY CARRIAGE AND PRIVATE HIRE DRIVER: YES/NO

10. DO YOU GIVE YOUR CONSENT FOR THE COUNCIL’S MEDICAL ADVISER TO CONSULT YOUR DOCTOR, IF NECESSARY, ON THIS APPLICATION OR ANY SUBSEQUENT RENEWAL APPLICATION: YES/NO

B O R O U G H O F T A M W O R T H Licensing, Public Protection, Assets & Environment Application for Hackney Carriage and Private Hire Drivers License

4 Medical Questionnaire

FOR OFFICIAL USE ONLY

I CERTIFY THAT ON ______I CARRIED OUT AN EXAMINATION OF THE APPLICANT AND I AM/AM NOT SATISFIED THAT HE/SHE IS MEDICALLY FIT TO CARRY OUT THE DUTIES OF A HACKNEY CARRIAGE AND PRIVATE HIRE VEHICLE DRIVER

Signed ------

Official Stamp Medical Practitioner

FOR OFFICIAL USE ONLY

APPLICATION

DATE OF RECEIPT OF APPLICATION AMOUNT OF FEE PAID 5 RECEIPT NUMBER

DRIVING LICENSE

ISSUE NUMBER LICENSE NUMBER REFERENCE NUMBER IF ANY CONVICTIONS – COPY LICENSE OR CHECKED AND COPIED

MEDICAL

DATE: TIME: DOCTOR:

DATE POLICE MEDICAL DVLA KNOWLEDGE

POLICE

MEDICAL

K/LEDGE FORM SENT

FORM RET'D

CHECKED

LICENSE

LICENSE NUMBER DATE OF ISSUE

6 PLEASE DETACH & KEEP FOR FUTURE REFERENCE

NOTE 1 - CRIMINAL CONVICTIONS

- Rehabilitation of Offenders Act 1974

All criminal convictions must be disclosed whether spent or otherwise in accordance with Rehabilitation of Offenders Act 1974 (exemption) Order.

NOTE 2 - DRIVING LICENSES

Before an application is submitted you must ensure that the driving license is up to date and that in particular:

a. Your current address is recorded on the driving license. b. Any current motoring convictions/endorsements have been recorded on the license by the DVLC, Swansea.

NOTE 3 - MEDICALS

It is a condition of the license that licensees under 45 years of age will be required to undergo a medical examination at five year intervals. Licensees from 45 years to 65 years of age will require medicals at 3 year intervals and licensees over 65 years will be medically examined annually.

NOTE 4 - COMPETENCE TEST (Initial Application or Renewal after lapse of 3 years or more)

You will be required at a date and time to be arranged, to attend for assessment of your competence and knowledge of the district. Details of which are overleaf.

YOU MAY BE ASKED TO DESCRIBE HOW TO GET TO 3 OR MORE OF THESE ROADS OR LOCATIONS BY THE SHORTEST AVAILABLE ROUTE, AND WILL BE ASKED TO DESCRIBE THE LOCATION OF APPROXIMATELY 20 OF THE LISTED ROADS AND LOCATIONS.

THOSE WHO ARE ABLE TO SHOW THE CORRECT KNOWLEDGE OF 80% OR MORE OF THE ABOVE, WILL BE CONSIDERED TO HAVE SUFFICIENT KNOWLEDGE OF THE DISTRICT.

7 TAMWORTH BOROUGH COUNCIL HACKNEY CARRIAGE AND PRIVATE HIRE DRIVER ESSENTIAL KNOWLEDGE REQUIREMENTS

Abbey Road Moor Street,The Leys Albert Road Ninian Way Aldergate Offadrive Amington Road Overwoods Road Apollo Park Farm Road Argyle Street Peelers Way Ashby Road Pennine Way Birds Bush Road Pennymoor Road Blackwood Road Perrycrofts Crescent Bolebridge Street Riverdrive Bonehill Road Salters Lane Brindley Drive Sandy Way Browns Lane Saxondrive Buckingham Road Sheepcote Lane Campion Drive Shuttington Road Chiltern Road Silver Link Road Church Street Spinning School Lane Claremont Road Tamar Road Colehill Tamedrive Comberford Road Tamworth Rd (Amington) Coton Lane Tamworth Rd (Dosthill) Cottage Farm Road Tamworth Rd (K'brook) County Drive Thackeray Drive Crowden Road Thomas Guy Way Dosthill Road Tinkers Green Road Fazeley Road Tom Williams Way Field Farm Road Torside Fontenaye Road Upper Gungate Fossdale Road Vangard George Street Ventura Park Road Gillway Lane Victoria Road Glascote Road Watling Street Hedging Lane Wigginton Road High Street (Dosthill) Wilnecote Lane Hockley Road Woodland Road Holloway Kerria Road Amington Industrial Estate Kettlebrook Road Beauchamp Park Industrial Estate Leyland Road Lichfield Rd Industrial Estate Lichfield Road Tame Valley Industrial Estate Lichfield Street Two Gates Trading Estate Lower Gungate Malham Road Sir Robert Peel Hospital Mariner Rawlett School Market Street Tamworth College Marlborough Way Tamworth Police Station Masefield Drive Tamworth Railway Station Mercian Way Magistrates Court Wilnecote Rail Station

Assembly Rooms Casa Kube Trinity Snowdome Peaks Leisure Centre Tamworth Town FC