02380 554100

Transfer application form

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It may be useful for your Doctor / Consultant /Health Professional to have a copy of your report. If you would like us to send them one them please put their details below.









Section 1. Personal details




































Section 2. NATURE OF DISABILITY OR PROBLEM(S)

If you already hold a driving licence and you develop a medical condition that could affect safe driving, then you are legally required to inform the DVLA. We may be unable to carry out the on-road drive part of your assessment if this has not been done.












Section 3. MOBILITY DETAILS

If you receive the Higher Rate component of the Disability Living Allowance please call Motability on 0300 456 4566 and ask to be referred to Wessex DriveAbility for an assessment














Section 4. DETAILS OF AIDS AND EQUIPMENT









Section 5. TRANSFER ISSUES






















Section 6. Payment

You can pay by cheque made payable to ´Wessex DriveAbility´, please write your name and address on the reverse and send your cheque to Wessex DriveAbility, Leornain House, Kent Road, Portswood, Southampton, SO17 2LJ. You can pay online via PayPal (please note you do not require a PayPal account to use this service and a £2.75 administration fee applies).



Online Payment Cheque

Section 7. Declaration

By completing and returning this Application Form to Wessex DriveAbility you are giving consent to undertake a Driving Assessment. Your consent may be withdrawn at any time. Under the Data Protection Act 1998 you have the right to enquire in writing what personal information the assessment centre holds about you and subject to status, you may be supplied with a copy of this information.


I declare that I have checked the details I have given on this form and that they are correct to the best of my knowledge

Yes


I fully understand that in exceptional circumstances Wessex DriveAbility may have a Duty of Care to inform the DVLA of the findings and outcome of this assessment.

I Agree








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Leornain House Kent Road Portswood Southampton SO17 2LJ
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