Membership Form Please enable JavaScript in your browser to complete this form.Name *FirstLastMobileMobile numberHome phoneHome phone numberWork numberWork numberEmail *Organisation nameIf you are joining because your organisation(s) wants or want you to use our cars for trips, please specify their name(s) here. Other family membersFamily Membership allows two or more full members to only pay one monthly membership fee and is limited to a maximum of 4 people at the same address. If this applies to you, write in names of other family member(s) so we can link them to you. Choose a tariffCasual user (£0 per month)Light user (£3 per month)Frequent user (£10 per month)• Casual user tariff: £1.50 per hour and 35p per mile • Light user tariff: £1.25 per hour and 30p per mile. • Frequent user tariff: £1.00 per hour and 25p per mile. Cost of charging or fuel is included. If the mileage driven for your entire booking is more than 150 miles then you pay a reduced mileage rate of 10p for each mile above 150. This applies to all the tariffs. Cost of charging or fuel is not included.Date of birth *Occupation(s) *Please be specific: job title and business worked in or retired/unemployed if not working. We require this as certain occupations are not covered by our insurance.First line of your Address *Village or Town *Postcode *Driving licence number *Type of UK driving licence held *FullProvisionalEuropean or European Economic AreaOtherHave you ever had any insurance refused, cancelled declared void (as though it never existed), renewal declined, or special conditions imposed by the insurer? *NoYesIn the last 5 years have you had any County Court Judgements (CCJs) made against you? *NoYesHave you ever had any form of bankruptcy or statutory insolvency proceedings? *NoYesHave you had any non-motoring criminal offences including convictions and charges not yet tried? *NoYesIn the last 5 years have you had any motoring accident or loss or made any motor insurance claim, including personal injury? *NoYesIn the last 5 years have you been issued with an endorsable fixed penalty notice or been convicted of, or received a police caution for, any motoring offence? *NoYesHave you ever had any driving convictions? *NoYesDo you suffer from any of the conditions which must be notified to the DVLA? *NoYesIf you answered Yes to any of the above questions please add more detail belowWe need your current licence summary from the DVLA. Go to https://www.gov.uk/view-driving-licence and follow the instructions. You will need your driver licence number, national insurance number and post code. Once logged in: Click on the tab “Get your check code”, Click the button “Get a code” and enter it below. *Check codeHow did you hear of us? *I confirm that all the above information is correct and that I have read the membership agreement and agree to be bound by its terms. *I understand that my application may be declined if our checks reveal any errors or inaccuracies.Submit
