WORCESTERSHIRE GROUP OF ADVANCED MOTORISTS

ASSOCIATE MEMBERSHIP APPLICATION  / ORDER FORM *

Registered Charity No. 1003399. Data Protection Act Registration No.X3212285

PLEASE COMPLETE IN BLOCK CAPITALS AND BLACK INK              * Products may be ordered without joining

 

Full Name: Mr/Mrs/Miss/Ms ...........................................................................................................................................

 

Address:...............................................................................................................................................................................

 

..........................................................................................Post Code:.......................................................

 

Tel. No.:..........................................................Mobile:..................................................Email: ………………………….

 

Date of birth:** ...........................................Occupation:...............................................................................................

 

(The last two are to assist in the selection of a suitable Observer and for statistics purposes )

 

            ** Please note that Associates under 18 years of age must be accompanied by a responsible adult

 

[please √]  where appropriate - I apply for

 

Amount

[   ]

IAM Skill for Life Associate Membership, includes "How to be a Better Advanced Driver" handbook

 

£85

(£99 from 1st April 2008 )

(£20 less for under 26s) 

 

OR

[  ] IAM DriveCheck, single 60 minute driving assessment

£25

 

 

              By credit card on form or cheque payable to “The Institute of Advanced Motorists”

 

Please you MUST ALSO complete and return a Skill for Life application form now

 

[   ]

Roadcraft" Police Drivers' Handbook, a strongly advised purchase, latest edition

£14.99

 

[   ]

The Highway Code 2007 edition

£ 2.50

 

[   ]

Roadcraft Video" 1.5 hrs: Met. Police Advanced Driving Course, highly recommended

VHS tape: £14.99

DVD         £15.99

 

[   ]

"Know Your Traffic Signs", latest, 1995 edition, 99 pages of signs and explanations

£ 3.00

 

[   ]

"The IAM Minibus Driver's Guide" 38 pages with illustrations

£ 1.50

 

[   ]

Vehicle sticker: "PLEASE KEEP A SAFE DISTANCE, 2 seconds minimum, 4 secs. when wet"

£ 2.75

 

I enclose a cheque payable to “Worcestershire Group of Advanced Motorists”

for the total of

 

 

*If applying for Associate Membership, please also complete the following:

Your vehicle Make & Model: ....................................................................................  Manual/Automatic

Colour:.......................................................Registration:..............................................................

 

Day

Mon

Tue

Wed

Thu

Fri

Sat

Sun

 

Morning

 

 

 

 

 

 

 

 Please indicate, with ticks, when you would normally

 be available for observed runs.

 Your Observer will usually suggest one run per week

Afternoon

 

 

 

 

 

 

 

Evening

 

 

 

 

 

 

 

 

How far you are you willing to travel to meet your Observer? 5 / 10 / 15 / 20 / 25 / 30 miles.

(The further you are willing to travel, the shorter your wait may be). We do not ask Observers to travel to Associates.

 

1. Are you able to read a new style vehicle number plate (with spectacles or contact lenses if required)

from a distance of 20 metres (66 feet) -about five car lengths? (THIS WILL BE VERIFIED) Yes / No

2. Do you have any disability or are you receiving any medication?  Yes / No

3. Within the last 3 years, have you been disqualified or received penalty points as a result of a court conviction or a fixed penalty notice?

(A small number of existing points on your licence will not normally preclude you from taking the Advanced Driving Test)

Yes / No.  If Yes to 2 or 3, please detail overleaf.  This information is required for the Group's insurance.

 

How did you hear about us?  Police Finer Driving Course / Young Driver Scheme / Motor Show / IAM headquarters

Driver Improvement Course / 3 Counties Show / Motorway Guidance / Friend / Newspaper / Radio/

 

or via Group Member............................................................(name)  Other: ..................................................

 

I hold a full, valid Driving Licence in my name for the vehicle, have valid insurance and have an MOT Test certificate if applicable

Signed:.................................................................................... Date:.................................................................

 

Please note that it is you, the driver, who is deemed to be in control of the vehicle at all times during an Observed Run.

Please return to Mr Howerd Brooksbank, WGAM Secretary, 11 Froxmere Road, Crowle, WORCESTER, WR7 4AU.

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Office Use: Payment Recd:                                Date Allocated:

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