Name

First Name

Last Name

Production Company (if any)

Date of birth

Email Address

Driving licence number

Date passed driving test

Have you been convicted of any motor offences in the last five years or are any prosecutions pending?

If Yes, please complete the following:

Have you ever been disqualified from driving?

If Yes, please complete the following:

Have you ever been declined for Motor Insurance or had any Special terms applied?

If Yes, please complete the following:

Do you suffer from any medical condition that you have had to declare to the DVLA, or may affect your fitness to drive?

Neurological Disorders

Cardiovascular Disorders

Diabetes

Psychiatric Disorder

Visual Disorders

Renal Disorders

Respiratory and Sleep Disorders

None of the above

Signature

Date

YYYY

IMPORTANT: Please e-mail a photo or scan of your photo licence front and back to mail@electra-tv.com

Done

Driver declaration

+44 (0)20 8232 8899