Skip to main content
Page 1 of 8

Driver Application and Medical Questionnaire

Please complete the fields in this form, ensuring you upload all required documents, and click the Submit Application button on the last page.

Note that each page of this application will verify the fields have been completed successfully. When you click 'Next' this may take a few seconds before it shows the next page.

Personal Details

Enter your First Name
Enter your Last Name
Invalid email address.
Please enter your address
Please enter your postcode
Please enter your telephone number
Please enter a second telephone number
Please enter your current job title
Please disclose residency outside the UK
Please upload an image
Please upload an image
Please upload an image


Note: When you click 'Next' to proceed to the next section, our system will automatically validate your answers. This process may take a few seconds. During this time, please do not refresh the page or click 'Back' in your browser, as this may disrupt the validation process and could require you to re-enter information.

Convictions and Experience

Have you had any motoring convictions in the last 5 years, including enquiries or prosecutions pending but excluding 'spent' convictions under the rehabilitation of offender's act 1974. (If yes, please give full details in the revealed field)(*)
Have you had any motoring convictions in the last 5 years, including enquiries or prosecutions pending but excluding 'spent' convictions under the rehabilitation of offender's act 1974. (If yes, please give full details in the revealed field)
Please select an option
Please list your endorsements
Have you ever been convicted of or charged but not tried with a Criminal offence other than motoring offences and spent convictions under the rehabilitation of offender’s act 1974? (If yes, please give details in the revealed field)(*)
Have you ever been convicted of or charged but not tried with a Criminal offence other than motoring offences and spent convictions under the rehabilitation of offender’s act 1974? (If yes, please give details in the revealed field)
Please make a selection
Please enter details

Accidents

Please enter details of any accidents

Your Experience

Have you taken any form of advanced or defensive driver training SAFED etc.? If yes, please give details in the revealed field(*)
Have you taken any form of advanced or defensive driver training SAFED etc.? If yes, please give details in the revealed field
Please select an option
Invalid Input
Have you had any experience or do you hold any qualifications in any of these areas(*)
Have you had any experience or do you hold any qualifications in any of these areas
Please make a selection
Invalid Input
Has any Insurer ever declined a proposal(*)
Has any Insurer ever declined a proposal
Please select an option
please enter details
Has any Insurer ever required increased premium or imposed special terms(*)
Has any Insurer ever required increased premium or imposed special terms
Please select an option
please enter details
Has any Insurer ever cancelled or not invited renewal of any policy(*)
Has any Insurer ever cancelled or not invited renewal of any policy
Please select an option
please enter details

Education and Training

Please provide details
please provide details

Employment History

Please enter an employer
Please enter their address
Invalid Input
please enter the job title
Please let us know about your previous duties
Please enter your salary
Please enter a length of time
Please enter your reason for leaving

No approach will be made to your present employer or past employer before an offer of employment is made to you.

Please tell us about your other jobs
Why are you the best person for this job
Please detail any holidays

Medical Questionnaire

Have you seen a doctor in the last 3 years for any kind of health problem?(*)
Have you seen a doctor in the last 3 years for any kind of health problem?
Please select an option
Please provide further details
Are you having, or waiting for, any treatment or investigations of any kind, at the moment?(*)
Are you having, or waiting for, any treatment or investigations of any kind, at the moment?
Please select an option
Please provide further details
Do you have a history of blackouts, fits, or epilepsy?(*)
Do you have a history of blackouts, fits, or epilepsy?
Please select an option
Please provide further details
Do you have diabetes, thyroid, or gland problems?(*)
Do you have diabetes, thyroid, or gland problems?
Please select an option
Please provide further details
Have you ever failed a medical or had any special conditions imposed for any employment? i.e. disability diagnosed under the Disability Discrimination Act(*)
Have you ever failed a medical or had any special conditions imposed for any employment? i.e. disability diagnosed under the Disability Discrimination Act
Please select an option
Please provide further details
Have you ever been retired on grounds of ill health from any employment?(*)
Have you ever been retired on grounds of ill health from any employment?
Please select an option
Please provide further details
Are you currently taking any medication (excluding contraception)(*)
Are you currently taking any medication (excluding contraception)
Please select an option
Please provide further details
Have you ever had mental health problems or psychiatric illness? i.e. nerves, phobias, stress, anxiety, depression or eating disorders?(*)
Have you ever had mental health problems or psychiatric illness? i.e. nerves, phobias, stress, anxiety, depression or eating disorders?
Please select an option
Please provide further details
Have you ever had issues with drug or alcohol dependency or misuse including prescription or recreational drugs?(*)
Have you ever had issues with drug or alcohol dependency or misuse including prescription or recreational drugs?
Please select an option
Please provide further details
Do you have any skin problems or allergies including latex allergy (e.g. eczema, asthma or dermatitis) or an adverse reaction to any medication or substance?(*)
Do you have any skin problems or allergies including latex allergy (e.g. eczema, asthma or dermatitis) or an adverse reaction to any medication or substance?
Please select an option
Please provide further details
Do you have any health condition or injury caused or made worse by work?(*)
Do you have any health condition or injury caused or made worse by work?
Please select an option
Please provide further details
Do you have any other medical condition that may affect your ability to perform the proposed job?(*)
Do you have any other medical condition that may affect your ability to perform the proposed job?
Please select an option
Please provide further details
Do you have any sensory problems with hearing, sight or speech that are not corrected by adaptive aids such as hearing aids or glasses?(*)
Do you have any sensory problems with hearing, sight or speech that are not corrected by adaptive aids such as hearing aids or glasses?
Please select an option
Please provide further details

Do you have any musculoskeletal conditions that affect your ability to perform work tasks i.e. back, neck or joint problems, that affect the following?

Standing(*)
Standing
Please select an option
Please provide further details
Walking(*)
Walking
Please select an option
Please provide further details
Sitting(*)
Sitting
Please select an option
Please provide further details
Stair Climbing(*)
Stair Climbing
Please select an option
Please provide further details
Lifting(*)
Lifting
Please select an option
Please provide further details
Driving(*)
Driving
Please select an option
Please provide further details
Kneeling, Squatting, Bending(*)
Kneeling, Squatting, Bending
Please select an option
Please provide further details
Manual Dexterity(*)
Manual Dexterity
Please select an option
Please provide further details
Co-ordination(*)
Co-ordination
Please select an option
Please provide further details
Have you ever suffered from heart attack, heart disease, angina or chest pain?(*)
Have you ever suffered from heart attack, heart disease, angina or chest pain?
Please select an option
Please provide further details
Have you developed or suffered from high blood pressure?(*)
Have you developed or suffered from high blood pressure?
Please select an option
Please provide further details
Do you have any sleep disorders?(*)
Do you have any sleep disorders?
Please select an option
Please provide further details
Have you had any serious operations or illness?(*)
Have you had any serious operations or illness?
Please select an option
Please provide further details

Disability Discrimination Act (DDA)

Do you have a disability?(*)
Do you have a disability?
Please select an option
Please provide further details
Has the DVLA been informed of any illness or disability declared above?(*)
Has the DVLA been informed of any illness or disability declared above?
Please select an option
Please provide further details

Insurance

Has any insurer declined a proposal?(*)
Has any insurer declined a proposal?
Please select an option
Has any insurer required increased premium or imposed special terms?(*)
Has any insurer required increased premium or imposed special terms?
Please select an option
Has any insurer cancelled or not invited a renewal of any policy?(*)
Has any insurer cancelled or not invited a renewal of any policy?
Please select an option

Referee 1

Please enter name of Referee 1
Please enter their job position
please enter their company
Please enter their address
Please enter a telephone number
Please enter a valid email address

Referee 2

Please enter name of Referee 1
Please enter their job position
please enter their company
Please enter their address
Please enter a telephone number
Please enter a valid email address

Confirm and Submit

I declare that the information in this form is complete and accurate. I understand that any false information or deliberate omissions will disqualify me from employment or may render me liable to summary dismissal.

Sign Above
Please sign this field
Please select the date
Invalid Input