APPLICATION FOR OR
GRANT RENEWAL
Surname (Mr/Mrs/Miss/Ms)
Forename(s)
Address
/
Email address
Contact telephone no(s)
Badge No.
PRIVATE AND CONFIDENTIAL
Post code
National Insurance no
Tel: 01753 875664 Email: licensing@slough.gov.uk Web: www.slough.gov.uk
Town and Country of birth
/
Date of birth
/ /
When completing this application please:
• Use BLOCK CAPITAL letters
Provide a response to every question. We will not accept your application if you have not completed every relevant section or if
required documents are missing.
Please specify the duration of licence
you wish to apply for:
1 year
3 years
Driving licence no
Please provide the ‘check code’ for sharing your DVLA drivers licence information:
I authorise Slough Borough Council to use the information detailed in this application to obtain the ‘check code’ on my behalf.
DVLA driving licence information
Are you registered with the Disclosure and Barring Service (DBS) update service Yes No
If yes, please provide your DBS certificate number no
Disclosure and Barring Service (DBS)
Private hire drivers licence
Hackney carriage drivers licence
Dual private hire & hackney carriage drivers licence
Have you previously held or applied for a hackney carriage, private hire or
dual drivers licence with SBC or any other licensing authority? Yes No
Have you ever had a hackney carriage, private hire or dual drivers licence:
(a) Refused Yes No
(b) Suspended Yes No
(c) Revoked Yes No
If yes, please give details including date, authority and reason:
If YES, which licensing
authority?
Previous licenses
During the last 12 months have you suffered from any illness or injury
which has affected your ability to drive? Yes No
If YES, please give details including, date, duration, condition, treatment and medication:
Did you notify the DVSA of the change in your medical circumstances? Yes No
Medical
New applicants only - Please give details of your previous or current occupation:
Renewals only
Do you have any other occupation? Yes No
If yes, please give details of any other occupations:
Previous or current occupation/employment
When submitting a grant or renewal application, you must inform SBC of all offences (as detailed below) you have ever had. You
must provide full details of any offences (please use a separate sheet if necessary). If you are subject to any outstanding charge or
summons, please provide details below.
Offence details, including date, sentence/penalty points, length of ban etc:
Type of offence Type of offence
Conviction(s)
Yes No
Drunkenness
Yes No
Caution(s)
Yes No
Drugs
Yes No
Reprimands
Yes No
Police bail
Yes No
ASBOs
Yes No
Police recommendation
Yes No
Warning(s)
Yes No
Indecency offences/
sex offenders register
Yes No
Community service orders
Yes No
Violence
Yes No
Restraining orders
Yes No
Dishonesty
Yes No
Fixed penalties
(including traffic offences)
Yes No
Behaviour guidelines issued
Yes No
Major traffic offences
Yes No
Police investigations
Yes No
Traffic convictions
Yes No
Plying for hire
Yes No
Declaration of offences
This section must be completed for all private hire applications. Hackney carriage and dual licence holders only require an operator
signature if they work for one.
All licensed private hire operators you currently work for must complete and sign below:
First operator
Operator Name
Operator licence No
Signature
Please print name
Date
Second operator
Operator Name
Operator licence No
Signature
Please print name
Date
Declaration of Private Hire Operator
click to sign
signature
click to edit
click to sign
signature
click to edit
Designed & Printed by Slough Borough Council TL/3640/02-08-18
Application date Badge fee
Receipt number DBS fee
Licence start date Knowledge test fee
Licence expiry date
OFFICE USE ONLY
I hereby certify that to the best of my knowledge and belief that the information I have given is correct. I have given it
knowing that I shall be liable to prosecution if I have knowingly or recklessly made a false statement or omitted any material
particular to this application. I accept that Slough Borough Council (SBC) reserves the right to clarify any of my answers or
require further information in accordance with the provisions of the Town Police Clauses Act 1847, the Local Government
Miscellaneous Provisions Act 1976 and any other modification or re-enactment thereof.
I acknowledge that the licence issued to me, remains the property of SBC and must be returned to the council on demand. I
understand I must return the licence (including the ID badge) within seven days following the revocation or suspension of the
licence under section 61 of the Local Government (Miscellaneous Provisions) Act 1976.
I confirm I give SBC the authority to use the information detailed in this application to check the status of my DBS certificate
via the on-line ‘update service’. I understand that, if necessary, SBC may request further information from other agencies
such as the Police.
Applicant Declarations
Officer signature
Date
Notes
Policy booklet issued
Signature of applicant
Date
I understand that my right to work and live in the UK may be checked with the Home Office as part of my licence application or at
any other time for SBC to confirm my immigration status. I understand that I must produce a Home Office approved document(s)
such as a valid passport or biometric residence permit, a copy of which will be securely kept by SBC. Where there are restrictions on
the length of time I have to work and live in the UK, I understand that a licence will only be issued to the visa expiry date. If I do not
comply with UK Immigration laws, I understand that the licence will lapse and that I must return it to SBC. Failure to do so is a
criminal offence.
Immigration Status
click to sign
signature
click to edit
click to sign
signature
click to edit
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