RoSPA Advanced Drivers and Riders Emergency Service
Membership Application Form
Step One: Contact details, please complete in block capitals
Name:
Address:
Post Code:
Tel:
Email Address:
Date of birth:
Advanced Driving/Riding Details
Name of Qualification (please attach copy of current certificate)
……………………………………………………………………………………………………………………….
Emergency service (please tick)
Vehicle type (please tick)
Police
Car
Fire
Motorcycle
Ambulance
LGV
I am an Emergency Services Advanced Driver or Rider and would like to
become a Member at £20.00 (including VAT)*
*There after an annual subscription fee of £20 will be required
Step two: Remittance
Please chose your preferred method of payment
Cheque (Made payable to RoSPA)
Debit or Credit Card
(To pay by debit or credit card please call RoADAR on 0121 248 2099)
We are currently creating an online payment system; this will be available in July 2014
In 3 years time, unless you’re driving certificate/permit is still valid within your own emergency service
you will be required to take the RoADAR Advanced Test.
Gift Aid Declaration
I confirm I have paid or will pay an amount of income tax and/or Capital Gains Tax for each tax year
(6 April to 5 April) that is at least equal to the amount of tax that all charities or Community Amateur
Sports Clubs (CASCs) that I donate to will reclaim on my gifts for that tax year. I understand that other
taxes such at VAAT and council Tax do not qualify. I do understand the charity will reclaim 28p of Tax
on every £1 that I paid up to 5 April 2008 and will reclaim 25p of tax on every £1 that I give on or after
6 April 2008.
Please tick this box to declare gift aid
Declaration
I enter the advanced test and refresher tests of RoSPA Advanced Drivers and Riders entirely at my
own risk. I agree that The Royal Society for the Prevention of Accidents, its examiners, representative
members, officers, servants and agents shall not be liable to me for any loss, damage or injury or any
consequential or indirect loss (save for personal injury or death caused by the negligence of any the
aforementioned) sustained during or as a consequence of my undertaking any of the said tests. I
further undertake to indemnify the Royal Society for the Prevention of Accidents against all loss,
damage, claims or injury sustained by them by reason of any act, or omission or neglect of mine
during or as a consequence of my undertaking any of the said tests. I also agree to be bound by the
rules of RoSPA’s Advanced Drivers and Riders (available on request).
I confirm that the vehicle I use for the test will be roadworthy and that I have a valid driving licence,
insurance for the vehicle and MOT test certificate (where applicable) and that I will produce these
documents if requested.
Signature:
Date:
TERMS AND CONDITIONS
Payment details
A completed booking form indicating one of the following payment methods will denote acceptance of
the cancellation clause below.
Cheque: A cheque drawn on a UK bank is the preferred method of payment. Cheques should be
made payable to ‘RoSPA’.
Credit card: We are happy to accept payment by MasterCard / Visa / Amex. Please tick the box.
Cancellations: If you are prevented from keeping the appointment please let us know immediately. A
short notice postponement of less than three clear days will incur a cancellation charge (£35)
DATA PROTECTION ACT
From time to time we may write to you about our products and services. If you would prefer not to receive this
information please tick here
By completing this form, you consent to us disclosing your details to carefully selected third parties whose
products or services we believe may be of interest to you. If you would prefer us not to, you may write to us at
any time or tick this box
RoSPA Advanced Drivers and Riders, 28 Calthorpe Road, Edgbaston, Birmingham, B15 1RP.
Tel: 0121 248 2099 Fax: 0121 248 2050
Registered Charity No 207823 VAT Registration 655131649