Fleet Motor Policy Holder: Canterbury Christ Church University

Driver’s Declaration

Please answer all questions in BLOCK CAPITALS . You should read this form carefully before completing and signing. Please attach your original driving licence, including paper portion of photocard licence. Photocopies will be taken and held on file by University Transport Managers. Driver’s Full Name:

Driver’s title (circle as applicable): Mr Mrs Ms Miss Dr Prof Other Home address: (including postcode)

Date Resident within UK from: Date of Birth:

Full-time occupation:

Part-time / secondary Occupation (if any): Give details below of UK driving licence and period held (or full details of your EEC or overseas licence):

Date Test Passed: Expiry Date of Licence: Type of Licence: HGV PSV Ordinary Other: (circle as applicable) PROVISIONAL FULL Restricted:

How long have you regularly Haulage Vehicles: Taxis: driven? Please state how many Minibuses: Public service vehicles: months or years: Others: a- Have you resided permanently in the United Kingdom during the last 3 years? Yes / No b- Have you had a proposal declined, a policy cancelled or renewal refused or been Yes / No requested to pay an increased premium or had special terms imposed by an Insurer for Motor Insurance? c- Have you any physical or mental defect or infirmity or suffered from diabetes, fits or any Yes / No heart complaint? d- Have you been convicted of any motoring offence (including fixed penalty offences) or Yes / No had a licence suspended during the past 5 years or is any prosecution pending? e- Have you had any motor accident or made a motor insurance claim during the past 3 Yes / No years? f- Do you require spectacles or contact lenses for driving or are you hard of hearing? Yes / No g- Have you any points incurred on your licence which have not been updated onto your Yes / No paper licence by the DVLA? Details: (please continue overleaf if necessary)

Declaration: I declare that the information given above is to the best of my knowledge and belief correct and complete in every detail, that the driving licence I have submitted is my true and original licence and that the University may take up appropriate checks with DVLA and other such bodies should it be felt necessary. I will advise the University immediately should I incur more than 6 points on my licence, develop a medical condition or have an existing medical condition worsen which would affect my ability to drive a vehicle and is notifiable to the DVLA under the Highway Code. Dated: Signature of the Driver: