Driver Safety Declaration Form

Lets an applicant declare their health and driving history as part of the process to obtain a driving licence.

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Name

First Name

Last Name

Date of Birth

Have you had any convictions within the last five years?

Yes No

If yes, please provide details

Have you had any accidents within the last five years?

Yes No

If yes, please provide details

Do you suffer from any condition which could affect your ability to drive?

Yes No

If yes, please provide details

Do you have any official medical endorsements on your licence?

Yes No

Have you had an eyesight test within the last two years?

Yes No

Please attach a copy of your driving licence

Max 10 MB per file

Signature

Sign here

Date

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