Authorised Driver Registration Form

This form should be completed in conjunction with the Universitys guidelines for checking driving licences and following a visual check of a drivers ORIGINAL driving licence details, including any paper counterpart. The form must be signed and the original sent to the Transport Manager, Estates Office. A copy of this form should be held with a copy of the drivers licence by the respective department or office of the driver. Driver Details Title: UoW Staff Number Date of Birth: Job Title; UoW Department / Office: Licence Details Driving Licence Number: Issuing Authority e.g. DVLA: Date Issued: Renewal Date: / / / / / /

First Name:

Last Name:

Categories of Entitlement: Restrictions to Entitlement: Information Codes (if any): Endorsements/Driving Convictions Date of Conviction

Endorsement Code

Penalty Points

DECLARATION to be signed by the Driver and the Department Manager

1. I do not have a prosecution pending and agree to notify the University of any probable or pending
prosecution due to any alleged motoring offence.

2. I agree to notify the University immediately of any new convictions and endorsements, and any other
changes to my driving licence.

3. I agree to notify the University immediately of any medical conditions that affect my ability to drive,
which I acknowledge I must declare to the DVLA.

4. I agree to accept any driver training or driving assessment recommended to me by the University
designed to reduce risks and improve driver safety.

Signed by Employee:

Date:

I confirm I have seen and recorded details of the ORIGINAL driving licence and retained a copy of the drivers licence with a copy of this form.

Signed by Manager:

Date:

Authorised Driver Registration Form Issued by: Transport Manager

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