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Fill and Sign the Employee Medical Form PDF

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Application for a driving licence D9 counterpart for non-GB licence holders Please read the important notes over the page before filling in this form. Please use CAPITAL LETTERS and fill this form in black ink. Please put ✖ against all that apply: This form only applies to European Community/European Economic Area (EC/EEA) licence holders. Licence holders from Great Britain (GB) should use form ‘Application for a driving licence’ (D1) to apply for a photocard driving licence. Do you have a licence to drive: • buses – with 9 or more passenger seats or • lorries – weighing more than 3.5 tonnes? • are you a holder of a Northern Ireland (NI) driving licence? See note A. • was your licence issued by a European country? See note D. • are you currently resident in the United Kingdom (UK)? • do you wish to sit a test in the UK? If you can answer Yes to one or more of these questions – please read on. 1 What are you applying for? (See note B) ✖ ✖ First application to register your licence Removing out of date endorsements 3 Title: Mr Your details ✖ Mrs ✖ Miss ✖ Ms ✖ Other (for example, Dr) Surname: First names: Date of birth: Date of birth: D D MM Y Y Y Y ■■ ■■ ■■■■ Full current address House No. C To replace my licence counterpart as it has been: lost ✖ stolen ✖ defaced ✖ destroyed ✖ Add the following provisional entitlement to drive: (See note I for vehicle category descriptions) • Motorcycles – category A • Car – category B • Car with trailer – category B + E • Road rollers, tracked vehicles – category g, h • Large vehicles – category C • Medium-sized vehicles – category C1 • Large vehicles with trailers – category C + E • Medium-sized vehicles with trailers – category C1 + E • Buses – category D • Minibuses – category D1 • Buses with trailers – category D + E Postcode: ✖ ✖ ✖ ✖ ✖ ✖ ✖ ✖ ✖ ✖ ✖ ✖ • Minibuses with trailers – category D1 + E When applying for provisional bus/lorry entitlement you also need to submit a Medical Examination Report (D4). 2 Your conduct If you are applying for lorry entitlement, you should give details of findings of guilt, fixed penalties and cautions relating to drivers’ hours or records, roadworthiness or loading vehicles. If you are applying for minibus or bus entitlement, you should also tell us about any findings of guilt, fixed penalties and cautions for offences not relating to driving. Please also tell us about any driving offences committed by you. Court Offence Country you were born in: What date did you come to live in the UK? D D MM Y Y Y Y ■■ ■■ ■■■■ If possible, please provide a daytime phone number and/or email address where we can contact you if there is a problem with your application. Full phone/mobile number: Email address: Please enclose your current EC/EEA licence. It will be returned to you. Convictions (See note F) Date of offence Address on any previous counterparts: Sentence or fine Country of issue: Licence number: 4 Your signature You must fill in this section. Signature: Date: D D MM Y Y Y Y ■■ ■■ ■■■■ Use a separate sheet if you need to and attach it to this form. 7/11 Important notes A Northern Ireland licence holders only As a result of a change in legislation, from April 2009 Northern Ireland licence holders no longer have to apply for a GB counterpart to take advantage of the fixed penalty system. B Registering your licence The law requires all those who live in GB who drive buses – from 9 passenger seats – and vehicles weighing more than 3.5 tonnes – to be registered with the Driver and Vehicle Licensing Agency (DVLA). You are required by law to do this within 12 months of you taking up residence. Drivers who exchange their licence in GB are automatically registered. If your licence is lost or stolen, you would probably not be able to get a duplicate of your licence from the country it was issued in. However you will be able to apply for a GB licence from DVLA. Note: As a result of a change in legislation from April 2009, European Community (EC) or European Economic Area (EEA) licence holders will no longer be required to possess a GB counterpart to take advantage of the fixed penalty system. How to register Please fill in this form and send it, together with all parts of your national driving licence, to DVLA, Swansea SA99 1BH. If you are an EC/EEA licence holder you will be issued with a GB counterpart licence document. C Driving licence rules in GB As the holder of a licence issued by another EU member state or one issued in Iceland, Liechtenstein or Norway (see note D), provided your licence remains valid, you can drive in GB until age 70 or for three years after becoming resident whichever is the longer period. Expired licences are acceptable to exchange for a GB licence. The rules for holding a GB driving licence are almost certainly different from those in the country in which your licence was issued. The rules in GB for medical, driving conduct, road safety and driving licence renewal are those which you must observe if you live here. Bus/Lorry drivers When you are 45 years old and over, you will have to renew your licence every five years – 65 year olds have to renew annually – subject to passing a medical examination by your doctor. Once your EC/EEA licence expires or you reach the above age limits you must apply to DVLA for a GB licence. D Relevant countries You can register with us if your EU licence was obtained by exchanging a licence from one of the countries listed below. If your EU licence was obtained by exchanging from a country not listed below you will not be able to register. However, you will still be able to drive in the UK on your licence for up to a year, after which time you will have to apply for a GB licence. These are the relevant countries: Austria, Belgium, Bulgaria, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Liechtenstein, Lithuania, Luxembourg, Malta, Netherlands, Norway, Poland, Portugal, Republic of Cyprus, Romania, Slovakia, Slovenia, Spain and Sweden. E Medical conditions If you have ever had or presently suffer from any of the following conditions you must write to the Drivers Medical Group, DVLA, Swansea SA99 1TU or phone 0300 790 6806 with the nature of your condition, as it may affect your fitness to drive. • Diabetes controlled by insulin • Diabetes controlled by tablets • Epilepsy • Any conditions affecting either eye. Not including colour blindness or short or long sight • Any form of stroke including TIA • Fits or blackouts • Any type of brain surgery, severe head injury involving in-patient treatment, or brain tumour • Angina, other heart condition or heart operation • An implanted cardiac pacemaker • An implanted cardiac defibrillator (ICD) • Repeated attacks of sudden disabling giddiness • Any other chronic neurological condition including Multiple Sclerosis, Motor Neurone and Huntington's Disease • A serious problem with memory or periods of confusion • Persistent alcohol misuse or dependency • Persistent drug misuse or dependency • Serious psychiatric illness or mental ill-health • Parkinson’s disease • Sleep apnoea syndrome • Narcolepsy • Any condition affecting your visual field • Total loss of sight in one eye • Any persisting limb problem which needs driving to be restricted to certain types of vehicle or those with adapted controls • Severe learning disability YOU MUST TELL US IMMEDIATELY ABOUT A RELEVANT CONDITION OR A CONDITION GETTING WORSE, YOU COULD HAVE TO PAY A FINE OF UP TO £1000 IF YOU DO NOT. F Your conduct – Large goods and passenger carrying vehicles In all cases of questionable conduct the Traffic Commissioner for the area in which you live will decide whether to grant your entitlement to drive large goods or passenger carrying vehicles. Driving conduct You must tell us if you have any convictions for breaking the rules about: • drivers’ hours • the roadworthiness of vehicles • drivers’ records • overloading of vehicles Do not tell us about any convictions if they were more than four years ago. All endorsements on your licence will be taken into account when it is decided whether to give you entitlement to drive in GB. We will not give you entitlement to drive if you are disqualified from driving. Conduct not related to driving Passenger carrying vehicle (PCV) drivers only If you drive a minibus and/or bus, you must let us know about any court convictions you have had – even if they are not to do with driving, unless they have run out under the Rehabilitation of Offenders Act 1974. G Data protection Information contained in this form and the driving licence record to which it relates may be passed to third party organisations where there is a legal power to do so. Purposes for disclosure include checking your application, prevention and detection of crime, and research. Individuals may consent to the release of driver data to third parties for driving entitlement purposes. H Where to send your application Please send your application with your EC/EEA driving licence (and documentary evidence if required) to DVLA, Swansea SA99 1BH. If you have any questions about these arrangements, you can contact us in any of the following ways: • Phone 0300 790 6801 between 8am and 7pm Monday to Friday, or between 8am and 2pm on Saturdays. • Email go to www.direct.gov.uk/emaildvla • If you are deaf or hard of hearing and have a textphone, phone 0300 123 1278. I Vehicle category descriptions All weights refer to Maximum Authorised Mass (MAM) unless stated otherwise. Category Description Minimum age A1 Motorcycles Light motorcycles with an engine size of up to 125cc and a power output of up to 11kW (14.6bhp). 17 A Medium-sized motorcycles up to 25kW (33bhp) and a power to weight ratio of up to 0.16kW/kg. Motorcycles with a sidecar and a power to weight ratio of up to 0.16kW/kg. Notes 17 A Any size motorcycle, with or without a sidecar if you have completed the large motorcycle Direct Access Scheme. 21 B1 Three or four-wheeled light vehicles Motor tricycles, quadricycles and three or four wheeled vehicles with an unladen weight no more than 550kg. 17 B Cars Motor vehicle with a MAM of up to 3,500kg, no more than eight passenger seats with or without a trailer weighing no more than 750kg. As category B but with a trailer weighing more than 750kg. The total weight of the vehicle and trailer together can’t weigh more than 3,500kg. The weight of the trailer, when fully loaded, can’t weigh more than the unladen weight of the vehicle. 17 Automatic cars As category B with automatic transmission. 17 Cars with trailers As category B but with a heavier trailer that isn’t covered in the descriptions for category B. 17 See note 8 Medium-sized vehicles Vehicles weighing between 3,500kg and 7,500kg, with or without a trailer weighing no more than 750kg. 18 See notes 2 and 8 Medium-sized vehicles with trailers As category C1 but with a trailer weighing more than 750kg. The total weight of the vehicle and the trailer can’t weigh more than 12,000kg. The weight of the trailer, when fully loaded, can’t weigh more than the unladen weight of the vehicle. 21 See notes 2, 3 and 8 Large vehicles Vehicles over 3,500kg, with a trailer up to 750kg. 21 See note 3 Large vehicles with trailers As category C but with a trailer over 750kg. 21 See note 3 Minibuses Vehicles with a minimum of nine and a maximum of 16 passenger seats, with or without a trailer weighing no more than 750kg. 21 See notes 4 and 8 Minibuses with trailers As category D1 but with a trailer over 750kg. The total weight of the vehicle and the trailer together can’t weigh more than 12,000kg. The weight of the trailer, when fully loaded, can’t weigh more than the unladen weight of the vehicle. 21 See notes 4 and 8 Buses Any bus with more than eight passenger seats, with a trailer up to 750kg. 21 See notes 4 and 7 Buses with trailers As category D but with a trailer over 750kg. 21 See notes 4 and 7 B auto B+E C1 C1+E C C+E D1 D1+E D D+E See note 1 f Agricultural tractors 17 See note 5 g Roadrollers 21 See note 6 h Tracked vehicles 21 See notes 3 and 8 k Mowing machines or vehicles controlled by someone on foot 16 p Mopeds with an engine size of up to 50cc and a maximum speed of up to 50km/h. 16 Note 1 You can ride a large motorcycle at any age, two years after passing a test on a medium-size motorcycle . Note 2 You can drive at age 18 if you got your driving licence before 10 September 2009 and the weight of the vehicle and trailer together is under 7,500kg. Note 3 You can drive at age 17 if you are a member of the armed services. You can drive at 18 if one of the following apply: • you passed your driving test and Driver Certificate of Professional Competence (Driver CPC) initial qualification • you are learning to drive or taking a driving test for this category or Driver CPC initial qualification • you are taking a national vocational training course to get a Driver CPC initial qualification, or • you had your driving licence before 10 September 2009, you must take the CPC periodic training within 5 years of this date. Note 4 You can drive at age 17 if you are a member of the armed services. You can drive these vehicles at age 18 if one of the following apply: (i) You are learning to drive or taking a PCV test or Driver CPC initial qualification (ii) Having passed a PCV driving test and Driver CPC initial qualification, you can drive under any of the following conditions: • driving on a regular service where the route does not exceed 50km • not engaged in the carriage of passengers, or • driving a vehicle of a class included in sub-category D1. (iii)Having passed a PCV test before 10 September 2008 and driving under a bus operator’s licence, or minibus permit, or community bus permit and any of the following conditions: • driving on a regular service where the route does not exceed 50km • not engaged in the carriage of passengers, or • driving a vehicle of a class included in sub-category D1. You can drive at age 20 after passing a PCV driving test and Driver CPC initial qualification. For further advice you can contact the Driving Standards Agency by phoning 0300 200 1122 or by email at drivercpc@dsa.gsi.gov.uk Note 5 At 16 you can drive tractors less than 2.45m wide. It must only pull trailers less than 2.45m wide with two wheels, or four wheels that are close - coupled. Note 6 At 17 you can drive small roadrollers with metal or hard rollers. They must not be steam powered, weigh more than 11.69 tonnes or be made for carrying loads. Note 7 You need category D entitlement to drive an articulated bus (for example, a ‘bendibus’). You can get more details from us (see note H). Note 8 If you passed your test for category B or B automatic before 1 January 1997 your licence will already show C1, C1E (8.25 tonnes), D1, D1E (not for hire or reward) as entitlement. Note 9 You can drive at 17 if the Maximum Authorised Mass of the tracked vehicle is not more than 3,500kg.

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