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    Form Motor Vehicle Employee Declaration

    Uploaded by

    John Eddy
    This document is a declaration form for employees and volunteers of Benetas who drive vehicles for work purposes. It collects details about the driver such as their license and driving history to ensure road safety and compliance with occupational health and safety laws. The driver must declare any accidents or offenses from the past five years and sign acknowledging they will abide by Benetas' vehicle policies, allowing the organization to inspect the vehicle when needed. Benetas keeps this personal information private except for sharing it with those responsible for managing the vehicles and following related legal obligations.

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    © All Rights Reserved
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    Form Motor Vehicle Employee Declaration

    Uploaded by

    John Eddy
    24 views1 page
    This document is a declaration form for employees and volunteers of Benetas who drive vehicles for work purposes. It collects details about the driver such as their license and driving history to ensure road safety and compliance with occupational health and safety laws. The driver must declare any accidents or offenses from the past five years and sign acknowledging they will abide by Benetas' vehicle policies, allowing the organization to inspect the vehicle when needed. Benetas keeps this personal information private except for sharing it with those responsible for managing the vehicles and following related legal obligations.

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    Form-Motor-Vehicle-Employee-Declaration

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    This document is a declaration form for employees and volunteers of Benetas who drive vehicles for work purposes. It collects details about the driver such as their license and driving history to ensure road safety and compliance with occupational health and safety laws. The driver must declare any accidents or offenses from the past five years and sign acknowledging they will abide by Benetas' vehicle policies, allowing the organization to inspect the vehicle when needed. Benetas keeps this personal information private except for sharing it with those responsible for managing the vehicles and following related legal obligations.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    24 views1 page

    Form Motor Vehicle Employee Declaration

    Uploaded by

    John Eddy
    This document is a declaration form for employees and volunteers of Benetas who drive vehicles for work purposes. It collects details about the driver such as their license and driving history to ensure road safety and compliance with occupational health and safety laws. The driver must declare any accidents or offenses from the past five years and sign acknowledging they will abide by Benetas' vehicle policies, allowing the organization to inspect the vehicle when needed. Benetas keeps this personal information private except for sharing it with those responsible for managing the vehicles and following related legal obligations.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    MOTOR VEHICLE – DECLARATION FORM

    FOR TOOL OF TRADE AND OTHER BENETAS FLEET VEHICLES


    Benetas is committed to ensuring the health, safety and welfare of its employees, volunteers and others affected by its
    operation, including members of the public. Motor vehicles are considered to be a ‘workplace’ under Occupational Health &
    Safety legislation in Victoria and in accordance with the OH&S Act 2004. Therefore, Benetas’ commitment to OH&S extends
    to the use of motor vehicles for work or volunteer purposes. To assist us in meeting this commitment, we ask you to complete
    this form if:
    • you drive a Tool of Trade vehicle, pool car, bus or other Benetas Fleet vehicle; or
    • plan to use your personal vehicle for work purposes.
    Employee Details:
    Surname: Given Names
    Address: Department:
    Work No: Mobile: Date of Birth:
    Drivers Licence No: Licence Category:
    nd
    Number of years licensed: Photocopy attached: Yes No (* 2 Driver if req.)
    Vehicle Details:
    Year: Vehicle Make: Vehicle Model: Registration Number:

    Please indicate the amount of years/months experience you have driving vehicles similar in size Years:
    to the vehicle you have been provided with/selected. Months:
    Driver Details : Spouse/De-facto Details (if secondary driver) :
    In the last five years, have you: In the last five years, has your spouse/de-facto:
    Had a motor vehicle accident or made a Had a motor vehicle accident or made a
    Yes No Yes No
    claim under a motor insurance policy? claim under a motor insurance policy?
    Had an insurance claim refused? Yes No Had an insurance claim refused? Yes No
    Had a driving offence, infringement, Had a driving offence, infringement,
    conviction (excluding parking fines) or Yes No conviction (excluding parking fines) or Yes No
    currently have one of these pending? currently have one of these pending?
    Had a driver’s licence or learner’s
    Had a driver’s licence or learner’s permit
    permit cancelled, suspended, reduced
    cancelled, suspended, reduced to a lesser Yes No Yes No
    to a lesser grade or had special
    grade or had special conditions imposed?
    conditions imposed?
    Had insurance declined, cancelled or a Had insurance declined, cancelled or a
    renewal refused or had any special renewal refused or had any special
    conditions imposed (including an Yes No conditions imposed (including an Yes No
    increased excess) on any insurance increased excess) on any insurance
    policy? policy?
    Please provide full details for any questions answered YES from above
    Date: Driver: Details: Fine and/or suspension period
    / /

    / /

    I, ____________________________, declare the answers and statements I have provided are true, correct and
    complete. I further acknowledge receipt of the Motor Vehicle Driver’s Handbook and agree to abide by all of
    the requirements mentioned therein and acknowledge I have read and understand the Motor Vehicle Fleet
    Policy. I acknowledge no other family members; other my spouse/de-facto can drive the Benetas vehicle.
    I further acknowledge that Benetas can request to inspect the vehicle from time-to-time and I will allow access
    as required, at least annually.
    Signed:_______________________________ Date:
    PRIVACY STATEMENT
    The company collects personal information about you, including your licence number, insurance details and your driving history and
    experience for the purpose of managing its tool of trade and packaged vehicles as well as meeting its obligations under OH&S Act 2004.
    Benetas will disclose this information to its employees or other persons who are responsible for the management of these vehicles and
    compliance with legislative obligations relating to these vehicles. If you do not provide Benetas with this information, we may have to restrict
    your use of the vehicle. You may access your personal information by calling the Benetas Volunteer Coordinator or the Contracts &
    Procurement Manager on (03) 8823 7900.
    Issued Date: July 2014
    Review Date: July 2015 Authorised: Finance Page 1 of 1

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