Hirer Information

Hirer's Name *

Address *

Town *

Post Code *

Please leave this field empty.

How long have you lived at this address? *

Home Telephone *

Mobile Telephone *

Work Telephone *

Email *

Date of Birth *

Occupation *

Nationality *

Journey Details

Period of hire *

Reason of journey *

Please indicate areas of use *

Driving History Licence Information

Country of Issue of Licence *

Driving Licence Categories Held *

Date driving test passed *

Date driving test passed *

Driving Licence Number *

The DVLA only record motoring convictions electronically, we need a Check Code from the DVLA to check you licence details. To obtain the Check Code, please phone the DVLA on 0300 083 0013, or log in to the DVLA's Service on https://www.gov.uk/view-driving-licence (you will need your National Insurance No)

Motoring Convictions in last 5 years

Do you have any motoring convictions?
NoYes

Offence 1

Date of Office

Date of Conviction

Conviction Code

No of points

Fine £

Offence 2

Date of Office

Date of Conviction

Conviction Code

No of points

Fine £

What motor vehicle claims, accidents, fires and thefts have you had in the last three years?

Claim 1

Claim 2

Medical Conditions

Driving Licence and Indentification Paperwork

Please indicate what style of driving licence you have been issued with and bring all parts with you on the day of hire. Please also bring two utility (or other) bills that have been issued in your name at your address, passport or other photo ID. We will retain copies of your documents for 12 months, failure to bring these documents with you, will results in you not being able to complete the hire.

Declaration

I declare that:-

• I have read the above questions and answers that have been completed accurately and fully by me or on my behalf from the information that I have supplied

• the statements and particulars given above are to the best of my knowledge and belief true and that no information has been withheld that may influence my acceptance as a driver

• I am not suffering from any loss of use of limb, eye, defective (not corrected) hearing or vision, any heart, diabetic, epileptic condition nor any other infirmity that should be disclosed to the DVLA/DVA or othr licencing authority

• I have not been convicted of any motoring or non-motoring offences other than those stated above

• I have held a full driving licence for at least two years

I agree that the information supplied :-

• may be used to check my identity and my suitability to drive

• may be shared with others to facilitate the arranging of insurance on my behalf and for the purposes and processing insurance claims

• may be shared with fraud prevention agencies and databases

I further agree to be bound by the terms and conditions of the insurance which I have seen and read or have had the opportunity to see and read. I understand that subject to the provisions of the Data Protection Act 1988, I am entitled, on the payment of a small fee, to receive a copy of the information held about me.