Currently held details

Please advise any changes

Name:

Address:

Postcode:

Tel. Day:

Tel. Eve:

Tel. Mobile:

e-mail:

Vehicle details Make and Model ………………………………………………………………………………………………………………………………………………….

Registration No. …………………………………………. Year........................ Engine size……………………………… Manual/Auto ………………………………..

Insurance details

Name of Insurer................................…………………………… Class of Cover................................ Private or Company …………………………………………

Contact details if Company or Block cover…………………………………………………………………………………………………………………………………………….

Driving Number………………………………………………….. Valid from………………………………………………………………………………………

Driving Convictions

Have you within the last three years been disqualified or received penalty points as a result of a court conviction or a fixed penalty notice? Please also give details if the offence occurred more than three years ago and the order of the court became effective within the last three years, or the period of disqualification expired within the last three years.

Yes _____ No _____ If yes, please give details

Offence........................................................... Period of disqualification if applicable…………………….. Date of conviction……………………………………………

Penalty points.......................... Fine…………………….. List of any proceedings pending……………………………………………………………………………………..

Details of incidents(s)...…………………………………………………………………………………………………………………………………….

Data Protection

The Institute may, from time to time, write to you and/or make your name and address available to approved companies so that you may be informed about products or services which may be considered of interest to you. If you prefer not to receive such information please tick the box. _______

I agree to receive marketing communications from the Institute and/or approved third parties via electronic mail Please tick the box _______

Declaration

I declare that to the best of my knowledge and belief the answers given above are true. I agree that the Institute and Group and their officers and employees shall not be under any liability for any injury, damage or loss whatsoever and however caused; and that I am bound by the Articles of he Association of the Institute and any of its Rules and Regulations lawfully made from time to time.

Signature............................................................... Date..............................

Town/city or postcode area preferred for test...................................................................................................................................

For IAM use

Date received at IAM House……………………………………………………… Examiner.............