UNIVERSITY OF WARWICK STUDENTS� UNION by HC120911162345

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									                                                                                                                                     CARD
                                                           CAR/7/8 SEATER                MINIBUS
                                                                                                                                      NO.
                                                           M/CYCLE COMM                    TRAILER

                                                           DATE OF ISSUE:                AUTHORISED:



                     WARWICK SU AND WARWICK SPORT DRIVER APPLICATION
       To be completed by those people wishing to be insured to drive vehicles on behalf of Warwick SU and Warwick Sport


UNIVERSITY NUMBER


SURNAME                                                         FORENAMES

TERM-TIME ADDRESS

TEL NO                                                          EMAIL ADDRESS

AGE               DATE OF BIRTH                                 Are you prepared to drive for other societies? YES              NO

CLUB/SOCIETY/DEPT (STAFF)                                                   UNIVERSITY COURSE

UK DRIVER NO.                                                               DATE DRIVING TEST PASSED

WHICH CLASS OF VEHICLES                                                     HOW MANY YEARS DRIVING EXPERIENCE

Do you suffer from any form of illness or disability which has to be declared to the Authorities to obtain a driving licence?
YES/NO If yes, please specify:

 Have you ever been involved in any accident in connection with a motor vehicle?                YES                NO


DATE                DETAILS OF ACCIDENT                                                    TOTAL COST (Own and third party)




Have you ever been convicted (or are there any prosecutions outstanding) for any offence in connection with a motor
vehicle? YES         NO             If yes, give details below.

DATE OF OFFENCE            DATE OF ACCIDENT                  TYPE OF CONVICTION                  CODE         PENALTY POINTS
                                                                                                  NO




WARRANTY
I warrant that the above statements are true and complete and there are no material facts which would
influence the acceptance or assessment of my proposal. I warrant that a charge equivalent only to running
costs will be made to persons carried in the vehicle and that the official capacity of the vehicle will not be
exceeded.

I agree to abide by the Union’s ‘Terms of Conditions of Hire’ and ‘Driver Responsibilities’ dated (September
2005) and will immediately notify in writing any fact that may change any information given above (e.g.
disability, accident or conviction).

I understand that any failure to disclose any material facts may prejudice entitlement to indemnity under
the insurance contract and I will be liable for all consequences of such failure.
       SIGNED:                                                                      DATE


  NEWDRIVER               PREVIOUS DRIVER             LICENCE : Card and Sheet              PHOTO                DEPOSIT



Please Tick off all documents Received


17/9/2008/AR

								
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