PRIVATE HIRE AND HACKNEY
CARRIAGE VEHICLE
Application for exemption on medical grounds
Name
Address
Post code E-mail
Telephone number Mobile number
Date of birth
Hackney Carriage vehicle Private Hire vehicle
Vehicle plate number
Vehicle registration
Badge number
Please tell us the medical reason why you are applying for an exemption.
Your condition will need to be confirmed in writing by a medical practitioner. Please provide the
original letter with your application form.
Surgery name
Surgery address
Post code Telephone number
The cost of this exemption is £25 and will need to be renewed with every badge application.
Signature
Full name
Date
For office use only not to be completed by the applicant
Fee received Receipt number
Date the completed application was received
Action
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