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GOOD REPUTE DECLARATION FORM

NOTES FOR APPLICANT

 This Good Repute Declaration Form must be completed in addition to the Garda Vetting Form. The purpose of this form is

to provide details of i) all infringements either in the Republic of Ireland or outside the State, and ii) any convictions not

resulting from Garda prosecution, either in the Republic of Ireland or outside the State. Where the applicant is a company or

co-operative, details of any convictions/infringements recorded against the company or co-operative must be entered on this

form. (Further information on completing this form can be found in Section 6 of the Guidelines.)

 Each person listed as a licence member, including the transport manager, company directors/secretary where applicant is a

company, and members of the co-operative committee of management where applicant is a co-operative, must complete a

Good Repute Declaration Form. The form must be completed in each case even if there is nothing to declare.

 If the applicant is a company or co-operative, a Good Repute Declaration Form must also be completed on behalf of the

company or co-operative named in Section B of this form by a company director/secretary or member of the co-operative

committee of management, as appropriate. Section A is not required to be completed for the company or co-operative itself.

 This form must be completed clearly and legibly in full using BLOCK CAPITALS.

Name of Applicant

(Note – Where the licence is in the name of a company or co-operative, that entity is the applicant.)

Section A (to be completed by each person listed as a licence member)

FORENAME:

SURNAME:

PREVIOUS NAME (if any):

DATE OF BIRTH: (dd/mm/yyyy)

PPS Number:

Section B (to be completed only where the applicant is a Company or Co-operative)

Name of Company or Co-operative: ________________________________________________________________

Name of person completing form on behalf of Company or Co-operative: __________________________________

Have you received a penalty for any infringement or any conviction not resulting from Garda prosecution, either in

the Republic of Ireland or outside the State?

(NOTE: If applicant is a Company or Co-operative, all convictions and

infringements recorded against the Company or Co-operative must be declared below.)

Yes

If yes, please provide details below (if necessary, use additional pages and attach)

Date of

Nature of infringement

Prosecuting

Place of infringement

Court

Penalty

infringement

or conviction

Authority

or conviction

(if applicable)

or conviction

DECLARATION

I, the undersigned, hereby declare that I have included all convictions / infringements recorded against me or against the

company or co-operative (if applicant is a company or co-operative) in the Republic of Ireland or outside the State.

Signature: _____________________________________

Date: ____________________

PLEASE PRINT ALSO (

) Position in transport business: ___________________________

(applicant/director/company secretary/partner/member of management committee)

Road Haulage Operator Licence Application Form - Ireland Department Of Transport, Tourism And Sport Page 11

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