If you prefer to apply online then please complete the form below IN FULL and submit. We will process the application as appropriate depending on the information sent and the payment method you specify.
PLEASE NOTE ALL DRIVING AND TRANSFER ASSESSMENTS ARE
FREE OFF CHARGE WHEN BOOKED AND COMPLETED BY THE END OF MARCH 2012.
PLEASE QUOTE WD1
Please complete all boxes before submitting
Doctor/Consultant/Health Professional Name
Doctor/Consultant/Health Professional Address
Section 1. Personal details
Title
First Name
Surname
Address
Post code
Contact Tel
Email
Date of birth (dd/mm/yy)
Your weight
Your height
Prefered centre
Section 2. Driving licence details
Type of licence
Full
Provisional
None
Driving Licence Number
Licence expiry date
Number of years driving experience (years)
If you already hold a driving licence and you develop a medical condition which lasts more than 12 weeks and 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.
Have you informed the DVLA about your medical condition/disability?
If yes, what is the current situation..
a) Your case is still being investigated by the DVLA
b) Your licence has been revoked
c) The DVLA have allowed you to continue driving
d) You have been issued with a Provisional Disability Assessment Licence
e) You surrendered your licence voluntarily when you informed the DVLA
f) Are there any restrictions related to your disability recorded on your licence?
If yes, please give details
Section 3. Current driving details
Are you still driving?
What transmission is this?
Make/model and approximate age of current vehicle
Please give details of any adaptations already fitted to your car:
Do you think you will be able to continue to drive this type of car?
If not currently driving, when was the last time you drove?
Section 4. NATURE OF DISABILITY OR PROBLEM(S)
Do you have any medical condition?
If you know the name of your condition e.g. stroke, head injury etc, please provide details here. If you don’t have a specific condition please can you give us much information as possible about how you are affected e.g. back pain, tiredness, memory problems, problems with co-ordination.
What are your current issues with driving?
Have you been assessed by a Mobility Centre before?
If YES, which centre did this take place?
Are you on any medication?
If YES state details
Section 5. MOBILITY DETAILS
Do you receive the Higher Rate Mobility Component of the Disability Living Allowance?
Can you walk at all?
If so, can you walk up to 5 meters?
Do you use a mobility scooter or wheelchair?
Do you require any aids when walking?
Do you have any problems getting into a car?
if yes, please give details
Any other information that may be relevant
Who is paying for the assessment?
How did you hear about us?
As part of our aim to reach everyone in the community, it would help us if you could tick one of these boxes for monitoring purposes:
Section 6. Payment
1. How to Pay
By Cheque
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.
Pay Online
You can pay online via PayPal (please note there is a £2.75 administration fee to use this payment method). Simply click on the 'Pay Online' tab.
Declaration: 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
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.
It is important to tick the following statement:
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.
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.
Please complete all boxes before submitting