Driver's Declaration
this form is for staff members who will be driving New Farm Confectionery vehicles only. if you are unsure if this relates to you, please contact your manager.
Name
*
First Name
Last Name
Home Address
*
Street Address
Street Address Line 2
City
State
Postcode
Date of Birth
*
-
Day
-
Month
Year
What type of vehicle license do you hold?
*
Have you held your full license (not L's or P's) for 2 years or more?
Yes
No
Date obtained full license (not L's or P's)
*
State of issue
*
Have you during the last 5 years had any accident or fire happen to a vehicle under your control? If yes please provide details
*
Yes
No
Details
Rows
Date of loss
Insurance company
Details of accident
Amount $
1.
2.
3.
4.
Have you ever been reported for, or charged with, or convicted of alleged drunkeness, or alleged use, or alleged possession of drugs? If yes please provide details
*
Yes
No
Details
Rows
Date of charge
Nature of charge
Penalty
1.
2.
3.
4.
Have you ever been charged with, or convicted of any criminal offence of any kind whatsoever, other than any offence described in questions above?If ‘Yes’, please provide details
*
Yes
No
Details
Rows
Date of charge
Nature of charge
Penalty
1.
2.
3.
4.
Have you ever suffered from any physical defect, infirmity, impairment or affliction of sight or hearing or a fit of any kind? If ‘Yes’, please provide details and state if it is necessary to wear / use an artificial aid to drive the vehicle.
*
Yes
No
Details
Declaration
I hereby agree that I will at the request of New Farm Confectionery Pty Ltd, within 14 days of receiving notice thereof, obtain from the appropriate authority, a complete and up-to-date record of offences in respect of which I have been reported and / or charged and / or convicted in connection with or as a result of the driving of any motor vehicle in any State or Territory of the Commonwealth of Australia or any other place and of all endorsements, suspensions or cancellations of any licence which I may have held entitling me to drive any motor vehicle and I hereby agree that if a dispute arises between me and the New Farm Confectionery Pty Ltd and their insurer, I will not object to the admissibility in evidence of such record or the truth of the matters contained therein.
Signature
*
Date
*
-
Day
-
Month
Year
Date
Submit
Should be Empty: