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Application for a Licence to drive a Hackney Carriage or Private Hire Vehicle

(Red Asterisk denotes all mandatory fields for completion)

This form should be completed on screen, printed off and signed before being returned with a completed Medical. Your Doctor must complete the medical examination and this service usually incurs a fee. Please contact your surgery direct to obtain a price for this service.

Both completed forms should be returned to:

The Hackney Carriage Office,Civic Offices, Knoll Street, Cleethorpes, North East Lincolnshire, DN35 8LN

Please note, the submission of both completed application forms does not guarantee you a Hackney Carriage/ Private Hire Licence. You may therefore wish to discuss this completed application form with the Hackney Carriage Licence Officer before proceeding with the medical examination.

To book an appointment or to discuss any query with this form telephone 01472 324035 or 324040

Full Name of Applicant

Title *

First Name

Surname *

Address Line 1 *

Address Line 2

Address Line 3

Postcode *

Date of Birth *

Birth Place *

Telephone Number

E-mail Address

Give Particulars of Employment over the last 5 YearsFor more than 1 employer please complete all of the details and use the 'ADD' button to repeat the process

Name and Address of Employer
Nature of Employment
Date From	Date From Month Day Year
Date to	Date to Month Day Year

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