If handwriting please complete in BLOCK CAPITALS
What type of licence is required? Please tick one area and one type only
Adur / Worthing / Hackney carriage / Private hire
Is this application a / Renewal / Additional / New
Your details
Title
Forename(s)
Surname
Address
Postcode
Phone Number
Mobile
E-mail Address
NI number / Nationality
Passport number / Date of birth / Age
Driving licence details
Driving licence number / Issue no / Endorsements
Card expiry date / Groups
Declarations:
Warning it is an offence knowingly or recklessly to make or omit any material
NO OFFENCES ARE SPENT - ALL OFFENCES MUST BE DECLARED
Please give details of any motoring convictions (if none write NONE)
Court / Offence / Date of conviction / Sentence/Fixed Penalty
Please give details of all Criminal Convictions / Cautions
including any notices / Injunctions / ASBO / Fixed Penalty Notices against you
and any pending court or criminal proceedings (if none write NONE)
Court / Offence / Date of conviction / Sentence/Fixed Penalty
Are you aware of any pending Court or Criminal proceedings which are currently being taken or likely to be taken against you relating to any offence? / Yes
No
If yes, please give the details below:
Licences
Do you hold or have you ever held a licence to drive a Hackney Carriage or
Private Hire vehicle issued by this or any other Council / Yes
No
If yes, please give the details below:
Hackney Carriage driver no / Private Hire driver no
Have you ever had a licence suspended /revoked? / Yes / No
If yes, please give details:
Do you have a sponsor?
Yes / No / Name of sponsor
Your health
Have you visited your GP or a medical consultant within the last 12 months for any reason that may affect your Group 2 entitlement? / Yes
No
If yes, please give details:
Are you receiving any medical treatment or taking any medication? / Yes / No
If yes, please give details:
Employment
Are you currently employed? / Yes / No
If yes, please give details:
Do you currently have a school contract? / Yes / No
If yes, please give details:
Are you currently at school college or university? / Yes / No
If yes, please give details:
UK residency
How long have you lived in the UK?
If less than 5 years, you are required to provide a certificate of conduct from ALL of the countries (outside the UK) you have lived in for this 5 year period
Country / How many years / Date from / Date to
Authorisation to work in the UK & point-based system
To comply with the Immigration, Asylum and Nationality Act 2016 we are required to check your eligibility to live and work in the UK. Please confirm that you are able to live and work in the UK and on request provide evidence. / Yes
No
Data Protection Act 1998
The information you have supplied will be recorded and maintained on our database of Applications for Licence to Drive a Hackney Carriage / Private Hire vehicle. We may also share this information with other organisations that handle public funds for the purpose of preventing and detecting fraud.
I certify that to the best of my knowledge the information given by me on this form is correct. Failure to sign and date above will render the application invalid.
Signed: / Date:
Warning: You will be liable to prosecution if you knowingly give false information in order to obtain a Licence
Please complete and sign the application form and return this application form to:
Taxi Licensing, Public Health & Regulation,
Adur & Worthing Councils,
Portland House,
44 Richmond Road,
Worthing,
West Sussex,
BN11 1HS
Tel: 01273 263144
email:
FOR OFFICE USE ONLYApplication fee / £ / Application receipt no / Date
DBS fee / £ / DBS receipt no / Date received
DBS No / DBS online registration no / Date sent
IDS mandate received / Date sent
Medical date
Medically fit? / Yes / No / Referral required / Yes / No
Immigration check
Yes / No / Date sent / Date approved
Photos / Yes / No / Complete application received date
Officer
Child Sexual Exploitation Training / Yes / No / Date completed
Disability & Equality Training / Yes / No / Date completed
Driving Assessment Pass Certificate / Yes / No / Date completed
Licence issued
Licence no
Badge no
Last updated 10-01-2018 HCD/PHD/0