*Have you ever been cautioned by the Police or any authority for any Yes No reason? *Do you have any traffic convictions (this includes any fixed penalty notices Yes No received)? *Are there any pending matters, including criminal, civil or traffic offences, for Yes No which you are being investigated by any authority either in the UK or in any other country? *Have you previously held a licence to drive Hackney Carriages/Private Hire Yes No Vehicles with Chorley Council? *Have you ever had a licence for Hackney Carriages/Private Hire driver, Yes No proprietor licence or an operators’ licence, refused, suspended or revoked? If you answered to any question above, please give a full explanation, including any civil or “Yes” pending matters: (Continue on a separate sheet if necessary) Declaration of Convictions, cautions and pending prosecutions details- including motoring, criminal and civil matters Date Type of Conviction Court or Offence or pending matter Penalty Convicted (Criminal, motoring, fixed Police penalty, caution or pending matter Example: Example: Example: Example: Example: 27/8/14 Motoring penalty Police SP30- exceeding the statutory 3 points and – speed limit a £60 fine Declaration of Medical Conditions In all you must also provide a medical form completed by your GP *Do you use any none prescription drugs or medication? Yes No *Have you any medical condition that would prevent you from conveying dogs Yes No or that would affect your ability to act as a licensed HC / PH driver? *Have you any medical conditions or illnesses that are currently being Yes No investigated? If you answered to any question please give a full explanation, including any civil “Yes” matters:
*Have you ever been cautioned by the Police or any authority for any reason? Yes No *Do you have any traffic convictions (this includes any fixed penalty notices received)? Yes No *Are there any pending matters, including criminal, civil or traffic offences, for which you are being investigated by any authority either in the UK or in any other country? Yes No *Have you previously held a licence to drive Hackney Carriages/Private Hire Vehicles with Chorley Council? Yes No *Have you ever had a licence for Hackney Carriages/Private Hire driver, proprietor licence or an operators’ licence, refused, suspended or revoked? Yes No If you answered “Yes” to any question above, please give a full explanation, including any civil or pending matters: (Continue on a separate sheet if necessary) Declaration of Convictions, cautions and pending prosecutions details- including motoring, criminal and civil matters Date Convicted Type of Conviction (Criminal, motoring, fixed penalty, caution or pending matter Court or Police Offence or pending matter Penalty Example: 27/8/14 Example: Motoring – penalty Example: Police Example: SP30- exceeding the statutory speed limit Example: 3 points and a £60 fine Declaration of Medical Conditions In all you must also provide a medical form completed by your GP *Do you use any none prescription drugs or medication? Yes No *Have you any medical condition that would prevent you from conveying dogs or that would affect your ability to act as a licensed HC / PH driver? Yes No *Have you any medical conditions or illnesses that are currently being investigated? Yes No If you answered “Yes” to any question please give a full explanation, including any civil matters:
New%20Driver%20renewal%20Form%2021.08.2018%20TF-DR-05-18.docx