Are you currently taking any medication which you have been advised may affect your
ability to drive? If yes, please provide details, including the dosage:
• I understand as part of my licence conditions I am required to notify the Licensing Service of
any medical conditions since my last medical was completed.
• I declare the information I have provided above is true to the best of my knowledge.
• I understand that if the information I have provided is found to be false, or I am found to have
intentionally omitted information, I will be in breach of my licensing conditions and could face
having my licence suspended or revoked.
• I declare that should there be any changes to my medical condition since the date of this
declaration, and the time I have had a new Group 2 Medical completed by my GP, I must
inform the Licensing Service immediately.
Find out how we use your personal information at rochdale.gov.uk/privacy