Drive Lincs Registration Form

Drive Lincs Registration Form
Learner Details:
Full Name*

First NameLast Name
Pickup Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your drop off address the same as pickup?*
If no, please state:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail
example@example.com
Emergency/Parent contact telephone no.*
Please enter a valid phone number.
Do you have a specific educational need, learning difficulty, DVSA notifiable disability or medical condition?*

YesNo
Please give us as much information about this as you can in order that we can best help you.
Have you notified the DVSA?

YesNo
Are you 17+ years old?*

YesNo
Are you 16 years old and recieveing PIP or Higher rate of mobility?

YesNo
Do you have your provisional licence*

YesNoAppliedAlready hold a licence
Driving Licence No.*
What is your availability for lessons:*

Monday AMMonday PMTuesday AMTuesday PMWednesday AMWednesday PMThursday AMThursday PMFriday AMFriday PMSaturday AMSaturday PM
Please state how many hours of previous driving experience?*
Confirm that you will wear sensible and comfortable footwear for driving.*
If you wear glasses, make sure you bring them to your lessons*
Have you taken your theory test?*

PassedAttemptedNo
Theory test pass reference number (leave blank if unknown):
Automatic car lessons are 2 hours and the lesson fee is £84

10hr block booking is £400
Can you commit to same lesson time & day each week?*

YesNo
Confirm you require lessons in an Automatic car?*
How would you like to pay for lessons:*

One at a time (£84)Block of 10 hours (£400)Not sure yet
Please confirm that you agree to pay for your lessons in advance (pay for your next lesson at the end of current lesson)?*
Do you already have a driving test booked?*

NoYes
Which Test Centre?
Date/time of test?

DayMonthYear
Date
Hour Minutes
Should be Empty:

Drive Lincs Registration Form

Automatic car lessons are 2 hours and the lesson fee is £84