PLACES DIRECTORATE

APPLICATION FOR A DUPLICATE PLATE/BADGE

Data Protection	The information provided on this form will if necessary allow the Council to contact other Local Authorities or organisations and both disclose and collect information from them in respect of this application.  If you would like further information about how the Council will use your information please contact 0121 704 6830.	

To be completed in BLOCK CAPITALS.  The fee should be returned with this completed form.

Name:
	
Address:

	

Plate No:
	Registration No:	

Badge No:

Operator:

Loss reported to the Police at:-

                                                                                        Date:	

Declaration:
I declare that the information given above is true to the best of my knowledge and that I have not wilfully omitted any necessary material.  I understand that if there are any wilful omissions or incorrect statements made, my application may be refused without further consideration or, if a licence has been issued, it may be liable to immediate suspension and subsequent revocation.  To prevent offences Solihull Metropolitan Borough Council may share certain information with your insurance company.
N.B.   A false statement may render an applicant liable to prosecution

Signature ……………………………………………….              Date …………………

By signing this form you agree to the Council if necessary contacting other organisations and both disclosing and collecting information from them in respect of this application. The information supplied by you may be shared with other Departments within Solihull MBC or other external agencies and organisations for the purposes of preventing and detecting fraud/crime.	

HCL/DUP