Experienced Driver Assessment Application Form

							             RoSPA Driver Assessment Application Form
STEP ONE (BLOCK CAPITALS) (*delete where applicable)
Name:
Address:

                                                        Post Code:
Email:
Contact number:
Date of Birth:
Are you a member of GEM?*                               YES / NO

STEP TWO Taking the Experienced Driver Assessment. (BLOCK CAPITALS)
Details of the vehicle you will use for the assessment (this will help the examiner to find you).

Make:                                               Model:

Colour:                                             Reg Number:


I accept that the assessment will last approx 1 hour and will take place at a mutually
convenient time and location.

I confirm that the vehicle I use for the assessment will be roadworthy and that I have
a valid driving licence, insurance for the vehicle and Test Certificate
(where applicable) and that I will produce these documents if requested.

DECLARATION
I enter the experienced driver assessment of RoSPA Advanced Drivers and Riders entirely at my own
risk. I agree that The Royal Society for the Prevention of Accidents, it’s examiners, representative
members, officers, servants and agents shall not be liable to me for any loss, damage or injury or any
consequential or indirect loss (save for personal injury or death caused by the negligence of any the
aforementioned) sustained during or as a consequence of my undertaking any of the said tests. I
further undertake to indemnify the Royal Society for the Prevention of Accidents against all loss,
damage, claims or injury sustained by them by reason of any act, or omission or neglect of mine
during or as a consequence of my undertaking any of the said tests. I also agree to be bound by the
rules of RoSPA’s Advanced Drivers and Riders (available on request).

Signature:                                                             Date:


If you have a learning difficulty, disability and / or a medical condition, please ensure that we
know what you need so that we can make all reasonable adjustments to help you succeed.




                            RoSPA Advanced Drivers and Riders,
  28 Calthorpe Road, Edgbaston, Birmingham B15 1RP. Tel: 0121 248 2127 Fax: 0121 248 2050
                  Registered Charity No 207823 VAT Registration 655131649
STEP THREE (BLOCK CAPITALS)
I would like to pay the Assessment Fee of £50 by:

Please indicate method of payment:

Cheque/postal order made payable to ‘RoSPA’.

Payment on receipt of invoice: Order Number
(Order number must be supplied for this option)

Credit/Debit Card:

Visa                  Mastercard                    Amex          Switch


Card Number:


Expiry Date:
      /

Security code (last three digits on the rear of the card):


Gift Aid

                                TERMS AND CONDITIONS
Payment details
A completed booking form indicating one of the following payment methods will denote
acceptance of the cancellation clause below.

Cheque: A cheque drawn on a UK bank is the preferred method of payment. Cheques
should be made payable to ‘RoSPA’.

Credit card: We are happy to accept payment by MasterCard / Visa / Amex. Please tick the
appropriate box above.

Invoice: If you wish to be invoiced prior to payment, an order number must be quoted on the
booking form. Invoices are payable on receipt.

                                                  NEXT STEPS

1. Please send your completed form and payment to RoSPA Advanced Drivers and Riders,
   28 Calthorpe Road, Edgbaston, Birmingham B15 1RP.
2. On receipt of your completed application form and fee, an examiner will contact you
3. If no one has contacted you within 28 days of sending your application, please contact
   us on 0121 248 2127.
4. If you are prevented from keeping the appointment please let us know immediately. A
   short notice postponement of less than three clear days will incur a cancellation charge
   (£35 maximum).




                             RoSPA Advanced Drivers and Riders,
   28 Calthorpe Road, Edgbaston, Birmingham B15 1RP. Tel: 0121 248 2127 Fax: 0121 248 2050
                   Registered Charity No 207823 VAT Registration 655131649