EmailMe Form - Driver Declaration Form

Name *

First Last

Email *

Student ID *

Name of Club/Society *

Driver's Licence Number *

Upload Driver's Licence *

*

	Yes	No
Have you resided in the British Isles for less than 3 consecutive years?
Have you been involved in any motor accidents during the past 3 years?
Have you ever been convicted of any motoring offences during the past 5 years, or is there any prosecution pending?
Do you suffer from diabetes, epilepsy, defective hearing or vision, heart condition, or any physical or mental disability, infirmity or disease?
Have you ever had any motor vehicle insurance you hold or have held, declined, cancelled or refused at normal terms?

Signature

Clear

I hereby warrant and declare that the above statements and particulars are true, and there is no material fact which should be disclosed. I agree to advise immediately any changes in particular. I understand that this data will only be used for the purposes of motor insurance and will be held in accordance with the Data Protection Act, 1998.