Car Club Membership Application Form - TrydaNi - Charge Place Wales Ltd. (Eng)

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Car Club Membership Application Form

Ready to join? If you’ve spoken to a local Car Club Coordinator and read our Terms and Conditions, please fill out the Membership Application Form below. We aim to process all applications within 48 hours.

Who can join?

If you:

Have a device connected to the internet
Are at least 25 years old
Have held a valid, clean driving licence for at least 2 years

Please note that further security checks on your driving licence are performed before you can be accepted, through the use of Driving Licence Check Codes. Click here to find out how to get your Driving Licence Check Code.

Have you read the Terms and Conditions of the Membership Form (V6.1) prior to completing this form? *

Yes
No (Please read the Terms and Conditions before completing this form)

Name *

First

Last

Which Car Club would you like to join? *

Please note - you'll be able to book cars from any of these Car Clubs, but this Car Club will be your main contact point. Check with your local Coordinator first before booking cars from other locations as they can only be returned back to the local Car Club.

Date of birth *

Members 71 and over will be asked to provide pictures of the front and back of their Driving Licence to provide to our insurance company.

Occupation *

Full address (House number, street, town, city and postcode) *

Landline number

Mobile number *

Email *

Driving licence number *

Driving licence check code *

For details on how to obtain a Driving Licence Check Code, please click here.

Driving licence type *

Have you ever had any insurance refused, cancelled declared void (as though it never existed), renewal declined, or special conditions imposed by the insurer? *

Yes
No

In the last 5 years have you had any County Court Judgements (CCJs) made against you? *

Yes
No

Have you ever had any form of bankruptcy or statutory insolvency proceedings? *

Yes
No

Have you had any non-motoring criminal offences including convictions and charges not yet tried? *

Yes
No

In the last 5 years have you had any motoring accident or loss or made any motor insurance claim, including personal injury? *

Yes
No

Have you been issued with a fixed penalty notice or been convicted of, or received a police caution for, any motoring offence? *

Yes
No

Have you ever had any driving convictions? *

Yes
No

If you answered "yes" to any of the above, please provide: Conviction Code, Points received, Amount of fine paid, Length of ban (if applicable), Blood alcohol reading (if applicable) and Length of custodial sentence (if applicable)?

Do you suffer from any of the below conditions, which are notifiable to the DVLA? *

An epileptic event
Sudden attacks of disabling giddiness, fainting or blackouts
Severe mental handicap
A pacemaker, defibrillator or antiventricular tachycardia device fitted
Diabetes controlled by insulin or tablets
Angina (heart pain) whilst driving
Multiple sclerosis
Parkinson’s disease
Any other chronic neurological condition
A serious problem with memory
A serious problem with confusion
A major or minor stroke
Any type of brain surgery, brain tumour or severe head injury involving hospital in-patient treatment
Any severe psychiatric illness or mental disorder
Continuing / permanent difficulty in the use of arms or legs which affects ability to control a vehicle safely
Dependence on or misuse of alcohol. Illicit drugs or chemical substances in the past 3 years - this does not include drink/driving offences
Any visual disability which affects BOTH eyes - it is not necessary to declare short/long sight or colour blindness
No

If you answered "yes" to any of the above, please give further details and whether or not DVLA have been notified

Please confirm that your membership will be a Trial Membership for the first 12 months, before you can have Full Membership (Full details available on the Terms and Conditions). *

I confirm that I will have a Trial Membership

Do you require a Family Membership? *

Yes (If yes, please have each member fill out their own versions of this form)
No

If answered "yes" above, please add in the names below of who will be sharing your Family Membership (Up to 3 others only, max of 4 can share a Family Membership)

Do you agree to the Terms and Conditions and declare that you are fit, legally able to drive and everything you have written is true and correct? Do you agree toll notify TrydaNi – Charge Place Wales Ltd. in writing of any changes to the above information as soon as is possible? *

I accept and agree

TrydaNi – Charge Place Wales Ltd.

75 Water Street,
Carmarthen,
SA31 1PZ

info@trydani.org

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