DATA PROTECTION, DECLARATION AND SIGNATURE
DATA PROTECTION – We collect, use and store your personal data so that we can
process your application for a replacement or duplicate Individual Approval Certificate
(IAC).
We may share your personal data if we have a lawful reason. For example as part of a
criminal investigation or to prevent fraud. Find out more at www.gov.uk/dvsa/privacy.
DECLARATION – I confirm that, as far as I know, all statements in this application are
Signature : Date :
Full Name :
Please Note : All ‘Declaration’ sections above must be completed.
A typed ‘Signature’ is acceptable if sending your form electronically.
You can pay the application fee by one of the following methods :
1. Cheques/postal orders - Payable to the ‘Driver and Vehicle Standards Agency’
(or ‘DVSA’) and only accepted with postal applications.
2. Credit/debit card - If you choose to pay by this method, then once your application
has been received, you will be contacted by email with instructions on how to
arrange your card payment.
3. Pre-funded account - If you are a regular user of the scheme this is the quickest
method to use. For pre-funded accounts, the signatory on the application must be a
delegate authorised to use the account. For more information on setting up a pre-
funded account, please go to our website www.gov.uk/dvsa.
Details of the current fees can be found on our website www.gov.uk/vehicleapproval
or
by telephoning our Customer Contact Centre on 0300 123 9000.
How are you paying for this application?
(Please tick one box)
Cheque / Postal Order
Payable to ‘Driver and Vehicle Standards
Agency’ or ‘DVSA’ (only with postal applications).
Payment to be made after application is received.
DVSA Pre-funded Account
PFA No. :
I hereby authorise the Driver and Vehicle Standards Agency to take the amount
stated below from my bank / pre-funded account in respect of my application.
£
.
Signature details : Please sign and print your name below if you are either the card
holder or PFA delegate. A typed ‘Signature’ is acceptable if sending your form
electronically.
Signature :
Date :
Full Name :
