Drive Lincs Registration Form
Learner Details:
Full Name
*
First Name
Last Name
Pickup Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is your drop off address the same as pickup?
*
Please Select
Yes
No
If no, please state:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: 00000000000.
E-mail
example@example.com
Emergency/Parent contact telephone no.
*
Please enter a valid phone number.
Format: 00000000000.
Do you have a specific educational need, learning difficulty, DVSA notifiable disability or medical condition?
*
Yes
No
Please give us as much information about this as you can in order that we can best help you.
Have you notified the DVSA?
Yes
No
Are you 17+ years old?
*
Yes
No
Are you 16 years old and recieveing PIP or Higher rate of mobility?
Yes
No
Do you have your provisional licence
*
Yes
No
Applied
Already hold a licence
Driving Licence No.
*
What is your availability for lessons:
*
Monday AM
Monday PM
Tuesday AM
Tuesday PM
Wednesday AM
Wednesday PM
Thursday AM
Thursday PM
Friday AM
Friday PM
Saturday AM
Saturday PM
Please state how many hours of previous driving experience?
*
Confirm that you will wear sensible and comfortable footwear for driving.
*
Please Select
Yes
If you wear glasses, make sure you bring them to your lessons
*
Please Select
Ok
I don’t wear glasses
Have you taken your theory test?
*
Passed
Attempted
No
Theory test pass reference number (leave blank if unknown):
Automatic car lessons are 1.5 hours and the lesson fee is £68
5 lesson block booking is £330
Can you commit to same lesson time & day each week?
*
Yes
No
Confirm you require lessons in an Automatic car?
*
Please Select
Yes
How would you like to pay for lessons:
*
One at a time
Book a block
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)?
*
Please Select
Yes
Do you already have a driving test booked?
*
No
Yes
Which Test Centre?
Date/time of test?
-
Day
-
Month
Year
Date
Hour Minutes
Submit
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