Commonwheels Community Interest Company

Car Club Hirer Driving Declaration

To be completed in full and submitted by the person joining Commonwheels.

Please read the terms and conditions.

Your contact details

Title:

First name:

Surname:

House number or name:

Street address:

Town:

Postcode:

Email:

Confirm Email:

Phone (day):

Phone (eve):

Where did you hear about Commonwheels:

Your personal information

Gender:

Date of birth:

Occupation or business :

Type of employment:

Do you hold a full licence to drive motor cars?		Period full licence has been held
Driving Licence Number
Have you any physical disability or disease, loss of limb or eye, defective vision or hearing?		Details
Have you been convicted of, or received a fixed penalty notice for, a motoring offence in the last 10 years or is any prosecution pending?		Details
Have you been refused insurance or had special conditions imposed?		Details
Have you had any accidents or losses in the last 5 years?		Details

Declaration

I declare that to the best of my knowledge and belief the above answers are true and complete and I have not withheld any material information. I undertake that any car hired to me will not be driven by an ‘excluded person’ as described in the terms and conditions. I have read and accept the terms and conditions of use