*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:
driving entitlements, e3ndorsement details, disqualifications, convictions, photo images and CPC details (where applicable). Medical information is not to be provided. This authority will expire when I cease to drive in connection with Chorley Council and in any case three years from the date of the grant of my licence. Name: Signed: Dated: Applicant Checklist- tick this column only All documents below must be presented for inspection- ONLY ORIGINAL DOCUMENTS WILL BE ACCEPTED Checklist to be completed by Customer Service- all documents to be colour copied and attached to IDOX record 1 EEA/UK passport Where not produced to CHECK THAT THE RIGHT TO WORK AND RESIDE VISA IS VALID AND IN CURRENT PASSPORT, refer to back office for referral to Home office before processing application Colour copied and checked by Customer Services (Initials of CSO) Passport No : Expiry date: OR 2 UK Birth Certificate Where not produced to VERIFY RIGHT TO WORK AND RESIDE, refer to back office for referral to Home office before processing application Colour copied and checked by Customer Services (Initials of CSO) No: AND 3 Passport style photo to be taken at the appointment with CBC ID against Photo taken at time of receipt and attached to IDOX reference. Colour ID passport photo taken by Customer Services (Initials of CSO) 4 Full DVLA issued driving licence Licence No: Colour copied and checked by Customer Services (Initials of CSO) Issue No: Group B Expiry: DVLA check code: 7 Enhanced DBS- Chorley Council issued This must be within 3 months of the renewal. ONLY CLEAR DBS CERTIFICATES CAN BE VALIDATED. Where any issues identified copy and refer to back Office. Copy and checked by Customer Services (Copies destroyed after application processed) (Initials of CSO) Ref: Date of issue: 8 Chorley Council II Medical This must be completed within 3 months of the renewal date and signed by own GP. Where issues identified refer to Licensing Recorded and checked by Customer Services (Initials of CSO) Dr Registration No: Date completed: 9 Safeguarding Training Date completed : Recorded and Checked by Customer Services 10 DATA Protection Mandate Signed and dated Recorded and checked by Customer Services (Initials of CSO) 11 HCD Renewal 4120/60085/000968 £182.06