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Road Haulage Operator'S Licence Application Form - Ireland Department Of Transport, Tourism And Sport Page 6

Have you ever been convicted of an offence in the Republic of Ireland or elsewhere?

Yes

Please provide details

DATE

COURT

OFFENCE

COURT OUTCOME

DECLARATION OF APPLICANT

I, the undersigned who have applied for a position as a __________________ hereby authorise An Garda Síochána to furnish to

Department of Transport, Tourism and Sport a statement that there are no convictions recorded against me in the

Republic of Ireland or elsewhere, or a statement of all convictions and / or prosecutions, successful or not, pending or completed, in the

State or elsewhere as the case may be.

Signature of Applicant: _______________________________ Date: ____________________

PLEASE PRINT ALSO (

)

_______________________________________________________________________________________

To be completed by Department of Transport, Tourism and Sport only

Authorised Signatory: ______________________________ (Department of Transport, Tourism and Sport)

PLEASE PRINT ALSO (

)

Registration Number: _________

_____________________________________________________________________________________

To be completed by the Garda Central Vetting Unit

According to Garda records there are no previous convictions recorded against the above named applicant:

the attached convictions appear on Garda Records:

the attached prosecutions are pending:

NOTE: Checks were carried out by this office based on the information supplied.

The convictions supplied may apply to the subject of your enquiry.

Please verify information disclosed with the applicant.

C.V.U.

Signed:

Member I/C

________________________________

Road Haulage Operator'S Licence Application Form - Ireland Department Of Transport, Tourism And Sport Page 6