Medical self certification statement form

  • Contact Information
    Please take care when entering your email address.
  • Name
  • Address
  • Medical self-certification statement
    For Private Hire & Hackney Carriage Drivers, who have a Medical Report due during the COVID-19 Pandemic.
  • Declaration of Medical Fitness - Has anything changed since you last medical which was submitted to the Licensing Authority?
  • I declare that to the best of my knowledge and belief the answers given in this form are true. I understand that if I knowingly or recklessly make a false statement or omit any material particulars from any part of the form, which includes a medical declaration, I will be guilty of an offence which is punishable by a fine of up to £1000.
  • Statement of licensing policy on the handling of disclosure information
    This authority is under a duty to protect the public funds it administers, and to this end may use the information you have provided on this form for the prevention and detection of fraud. It may also share this information with other bodies responsible for auditing or administering public funds for these purposes. For further information, see our Level 2 Fair Processing Notice or contact Trafford Council’s Audit & Assurance Section on (0161) 912 1275.