<p> RoSPA Experienced Driver Assessment Application Form</p><p>Step One: Contact details, please complete in block capitals Name: Address:</p><p>Post Code: Tel: Email Address: Date of Birth: Are you a member of GEM?* YES / NO Step Two: Details of the vehicle you will use for the assessment </p><p>The examiner will make contact to arrange the date and location of the assessment Preferred assessment location:</p><p>Step Three: Remittance Experienced Driver Assessment £50 </p><p>Cheque/postal order made payable to ‘RoSPA’. Credit/Debit card: Amex Visa Mastercard Card Number: </p><p>Expiry Date: /</p><p>Security code (last three digits on the rear of the card):</p><p>Name on card</p><p>Gift Aid Declaration I confirm I have paid or will pay an amount of income tax and/or Capital Gains Tax for each tax year (6 April to 5 April) that is at least equal to the amount of tax that all charities or Community Amateur Sports Clubs (CASCs) that I donate to will reclaim on my gifts for that tax year. I understand that other taxes such at VAAT and council Tax do not qualify. I do understand the charity will reclaim 28p of Tax on every £1 that I gave up to 5 April 2008 and will reclaim 25p of tax on every £1 that I give on or after 6 April 2008. Please tick this box to declare gift aid</p><p>Declaration I enter the experienced driver assessment of RoSPA Advanced Drivers and Riders entirely at my own risk. I agree that The Royal Society for the Prevention of Accidents, its examiners, representative members, officers, servants and agents shall not be liable to me for any loss, damage or injury or any consequential or indirect loss (save for personal injury or death caused by the negligence of any the aforementioned) sustained during or as a consequence of my undertaking any of the said tests. I further undertake to indemnify the Royal Society for the Prevention of Accidents against all loss, damage, claims or injury sustained by them by reason of any act, or omission or neglect of mine during or as a consequence of my undertaking any of the said tests. I also agree to be bound by the rules of RoSPA’s Advanced Drivers and Riders (available on request).</p><p>I confirm that the vehicle I use for the assessment will be roadworthy and that I have a valid driving licence, insurance for the vehicle and test certificate (where applicable) and that I will produce these documents if requested.</p><p>Signature: Date:</p><p>Please ensure that we are aware of any special requirements that you need so that we can make all reasonable adjustments to help you succeed.</p><p>Holders of a photocard licence must ensure their licence is valid and up-to-date. Old style paper licences will also be accepted. Failure to produce either of these licences will result in the test being cancelled and fees will apply.</p><p>TERMS AND CONDITIONS Payment details A completed booking form indicating one of the following payment methods will denote acceptance of the cancellation clause below. Cheque: A cheque drawn on a UK bank is the preferred method of payment. Cheques should be made payable to ‘RoSPA’. Credit card: We are happy to accept payment by MasterCard / Visa / Amex. Please tick the appropriate box below. Cancelations: If you are prevented from keeping the appointment please let us know immediatley. A short notice postponement of less than three clear days will incur a cancelation charge (£35)</p><p>DATA PROTECTION ACT From time to time we may write to you about our products and services. If you would prefer not to receive this information please tick here By completing this form, you consent to us disclosing your details to carefully selected third parties whose products or services we believe may be of interest to you. If you would prefer us not to, you may write to us at any time or tick this box</p><p>RoSPA Advanced Drivers and Riders, 28 Calthorpe Road, Edgbaston, Birmingham, B15 1RP. Tel: 0121 248 2099 Fax: 0121 248 2050 Registered Charity No 207823 VAT Registration 655131649</p>