Authorised Driver Registration Form – Private

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Authorised Driver Registration Form – Private & Confidential
This form should be completed by staff and students who are required to drive University owned/leased/hired
vehicles on University of York business under the University’s motor insurance. It should also be completed by those
who drive their privately owned vehicles on University of York business under their personal motor insurance.
Driver’s Details
Name:
Job Title:
University Email:
Department and Section:
Staff  Student  Associate 
Date Driving Licence Test Passed:
For students, associates, new drivers, and those under 25 the form must be countersigned
Age test passed if under 25:
Accident History
(Please give details of all accidents in the last 5 years, regardless of blame)
Date
Description
Current Endorsements and/or Convictions
Endorsement/Conviction Date Endorsement/Conviction Code
Fine/Ban/Penalty Points
Health
If you have health problems that may affect your ability to drive, have they been notified to the DVLA
and your motor insurer? (Please tick)
 YES – I have health problems and have notified the DVLA and my motor insurer
Please briefly describe your health problem: ____________________________________________
 NO – I have health problems but have NOT notified my insurer and/or the DVLA
 NOT APPLICABLE – I have NO health problems.
Are you able to read a vehicle number plate from a distance of 20 metres (with or without corrective
lenses)? (Please tick)
 YES
 NO
Declaration
1. I do not have a prosecution pending and will notify the University of York of any future prosecution
in relation to a contravention of the Road Traffic Act.
2. I confirm I have listed all convictions and/or endorsements above. Failure to declare all convictions
and/or endorsements may result in sanctions.
3. I shall notify my Section Head immediately of any changes in health conditions that might affect
driving ability.
4. If I drive my private vehicle on University of York business I confirm that:
a) I have valid motor insurance and that the policy includes business use.
b) My vehicle has a current MOT certificate, is serviced regularly and is roadworthy.
c) My vehicle has a current road fund licence.
Signed by Driver:
Date:
For students, associates, new drivers, and those under 25 the form must be countersigned:
Signed by Manager (if applicable):
Date:
Manager Print Name:
I accept that there is an additional £200 on the excess for drivers under 25 and those who passed their test less than 12 months ago.
I confirm that this student/associate will be driving on University of York business.
Please send the following to the Health, Safety and Security Department or insu[email protected]:
 Completed Authorised Driver Registration Form
 Photocopy of BOTH SIDES of photocard driving licence
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