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Mobile 07876 031 945

Create complex forms with ease


Your site comes with a contact form already set up but you can set up forms to be shown on any page in your site with any number of inputs. These can be made of any combination of Text (single & multi line), check boxes, radio buttons or drop down menus.



These can be individually set as obligatory fields that have to be filled in for the form to be sent.



This is an example of a form with over 60 inputs set up for a driveability supplier.



* indicates required fields


Section 1. Personal details



































Section 2. Driving licence details




Full Prov None
























Section 3. Current driving details




















Section 4. NATURE OF DISABILITY OR PROBLEM(S)

If you already hold a driving licence and you develop a medical condition that could affect safe driving, then you are legally required to inform the DVLA. We may be unable to carry out the on-road drive part of your assessment if this has not been done.




























Section 5. MOBILITY DETAILS

If you receive the Higher Rate component of the Disability Living Allowance or Personal Independence Payment please call Motability on 0300 456 4566 and ask to be referred to Wessex DriveAbility for an assessment



































Section 6. Declaration

By completing and returning this Application Form to Wessex DriveAbility you are giving consent to undertake a Driving Assessment. Your consent may be withdrawn at any time. Under the Data Protection Act 1998 you have the right to enquire in writing what personal information the assessment centre holds about you and subject to status, you may be supplied with a copy of this information.


I declare that I have checked the details I have given on this form and that they are correct to the best of my knowledge

Yes


I fully understand that in exceptional circumstances Wessex DriveAbility may have a Duty of Care to inform the DVLA of the findings and outcome of this assessment.

I Agree







Note : Personal information you submit on this form is not shared or permenantly stored.


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