Ralph Davies Ltd
 

Driver Application Form

Personal Details

Full Name
Address
Telephone Number
Date Of Birth   Place Of Birth
National Insurance Number
Status
(please tick)		   Single   Married   Widowed   Divorced   Number Of Children  
Next Of Kin
Address
Telephone
Education
What are your hobbies and interests?

Driving Experience/License Details

Date ordinary driving test passed   License No   Expiry Date
Date HGV driving test passed   Class
List endorsements or bans (please include Date, Conviction Category, Penalty Points/Period of Ban)
List any other convictions List accidents in last 3 years
Has any load, part load, vehicle or part of a vehicle for which you have been responsible ever been stolen or unaccountably damaged? Yes
   No
If yes to the above, please provide details
Describe the types of vehicles, loads and journeys which you have experience of
Has any load or part load of any vehicle for which you have been responsible ever fallen off? Yes
   No
If yes to the above, please provide details

Medical Questionnaire

Weight    Height 
Are you in good health?   Yes
   No
If no to the above, please provide details
Have you ever had treatment for:
  Diabetes   Yes No   Blackouts   Yes No
  Epilepsy   Yes No
Have you ever had an operation?   Yes No
If yes to the above, please provide details
Do you wear glasses?   Yes No   Are you colour blind?   Yes No
Do you have any other eyesight problems?   Yes No
If yes to the above, please provide details
Do you wear an hearing aid?   Yes No
Do you have any other hearing problems?   Yes No
If yes to the above, please provide details
Do you smoke?   Yes No
Are you currently taking any medicine/tablets?   Yes No
If yes to the above, please provide details
Are you presently suffering from any disability which could effect you being able to drive?   Yes No
If yes to the above, please describe and state how long the disability is expected to continue
Are you willing to have a Medical Examination?   Yes No