Driver Assessment Ireland Covering Letter-2 - Driver Assessments Ireland

SECURE REFERRAL FORM

Confidential Referral Details to Finalise your Assessment

PLEASE FILL ALL STEPS TO COMPLETE YOUR APPLICATION.

Arrange an assessment

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Covering Letter Form

We have a few questions we’d like you to answer: -

Your First Name :

Your First Name

Field is required!

Your Last Name:

Your Last Name

Field is required!

What is your Driving Licence No:

Licence No:

Please Enter Driving Licence No.

When does this Licence expire:

Select a date

Field is required!

When does your Motor Tax expire:

Select a date

Field is required!

When does your Vehicle Insurance expire:

Select a date

Field is required!

Insurance Company Name:

Field is required!

Eircode for your home:

Your home

Your Home?

When is your next NCT due:

Select a date

Field is required!

Your Email Address:

Your E-mail Address

Field is required!

Your Doctor/GP’s name:

GP’s name

Your Doctor/GP’s name

By signing below, you consent to giving us permission to process your personal data specifically for the purposes identified in accordance with GDPR.

Field is required!

please use your finger or mouse to sign

Date

Select a date

Field is required!

Please note a cancellation fee of €55.00 is payable if a driving assessment is cancelled with less than 48 hours notice.

Submit

Self Efficacy Form

Name

Field is required!

Date of birth

Select date

Field is required!

How confident do you feel doing the following activities?

Please score the following questions on a scale of 0-10 where 0 is not confident and 10 is completely confident.

Driving in your local area.

Field is required!

Driving in heavy traffic.

Field is required!

Driving in unfamiliar areas.

Field is required!

Driving at night.

Field is required!

Driving with people in the car.

Field is required!

Responding to road signs/traffic signals.

Field is required!

Driving around a roundabout.

Field is required!

Attempting to merge with traffic.

Field is required!

Turning right across oncoming traffic.

Field is required!

Planning travel to a new destination.

Field is required!

Driving in high speed areas.

Field is required!

Parallel parking.

Field is required!

Based on Adelaide Driving Self Efficacy Scale

Driver Assessments Ireland use the above information as part of your overall Driver Assessment. Information provided will only be shared with named third parties with your consent. This form will be held in accordance with General Data Protection Regulations (GDPR).

Submit

SECURE REFERRAL FORM

PLEASE FILL ALL STEPS TO COMPLETE YOUR APPLICATION.

We have a few questions we’d like you to answer: -

By signing below, you consent to giving us permission to process your personal data specifically for the purposes identified in accordance with GDPR.

please use your finger or mouse to sign

Please note a cancellation fee of €55.00 is payable if a driving assessment is cancelled with less than 48 hours notice.

How confident do you feel doing the following activities?

Based on Adelaide Driving Self Efficacy Scale

Driver Assessments Ireland use the above information as part of your overall Driver Assessment. Information provided will only be shared with named third parties with your consent. This form will be held in accordance with General Data Protection Regulations (GDPR).

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