PSVA 1 (DVSA 0356) 1 Jan 2021

APPLICATION FOR A PSV ACCESSIBILITY CERTIFICATE (NON-DDA APPROVED TYPE)

PSVA 1

Disability Discrimination Act 1995 PSV Accessibility Regulations 2000

FAILURE TO COMPLETE THE FORM ACCURATELY OR IN FULL COULD RESULT IN DELAYS OR REJECTION

1. APPLICANT AND VEHICLE DETAILS

Name of applicant :

Company Name :

Address :

Postcode :

Tel. No.:

Email :

Registration Mark :

Chassis (VIN) No. :

Chassis Make :

Chassis Model :

Body Make :

Body Model :

Which test location would you prefer? :

Does the vehicle require an Accessibility Certificate (DDA) to : i. Schedule One – Wheelchair accessibility (buses and coaches)? YES NO

ii. Schedule Two – General accessibility (buses)? YES NO

iii. Schedule Three – General accessibility (coaches)? YES NO

iv. the requirements of Annex VIII of ECE Reg. 107 or Annex VIIof Directive 2001/85/EC (general requirements); and the

YES NO

requirements of Regulation 8 of Schedule 2 or Regulation 7 of Schedule 3 of the Act (destination equipment); a vehicle being already built/approved to the general requirements of ECE Reg 107 or Directive 2001/85/EC. NOTE : The fee payable in respect of an assessment to this item shall be the same as applicable to an assessment to two schedules.

v.

the requirements of Regulation 8 of Schedule 2 or Regulation 7 of Schedule 3 of the Act (destination equipment

YES NO

only); being a vehicle already Approved to ECE Regulation 107 including full compliance with Annex VIII of that Regulation, or Directive 2001/85/EC including full compliance with Annex VII of that Directive. NOTE : The fee payable in respect of an assessment to this item shall be the same as applicable to an assessment to one schedule. (A copy of the vehicle’s Certificate of Conformity will be required to be submitted)

https://www.gov.uk/government/publications/specialist-schemes-testing-station-map

PSVA 1 (DVSA 0356) 2 Jan 2021

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2. DETAILS OF ALTERATIONS

Please complete the appropriate boxes below and provide brief details of any alterations to the vehicle or its carrying capacity as a result of changes to the vehicle to comply with the Accessibility requirements only. Changes not relating to compliance with the Accessibility Regulations must be notified on form VTP5.

Restrained wheelchair(s) YES NO Unrestrained wheelchair(s)

YES NO

Power operated lift YES NO Portable Ramp

YES NO

Power Operated Ramp YES NO Please provide brief details below of any alterations ▼

Is the vehicle is fitted with special features (that affect stability)?

Air Conditioning YES NO If YES, please give the location in the box below ▼

Retarder YES NO If ‘YES’, please give type

Alloy Wheels YES NO Double Glazing YES NO

Toilet YES NO Entertainment Monitor / Screen YES NO Crew Seats YES NO Crew Compartment YES NO

Carrying capacity : Before alteration After alteration

Upper

Lower

Standing

Wheelchairs

Crew seats

Has the weight of the vehicle changed because of the alteration? YES NO

Please provide the following : Maximum

Length (cm) Maximum

Height (cm) Wheelbase

https://www.gov.uk/government/publications/notification-of-an-alteration-to-a-public-service-vehicle-vtp-5

PSVA 1 (DVSA 0356) 3 Jan 2021

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3. COVID – 19 SPECIAL CONDITIONS

If your vehicle is required to be presented for an examination the following conditions will apply.

a) Conditions that apply at the time of examination:

• arrive at least 20 minutes prior to appointment time

• only one person to attend with the vehicle

• open all apertures including doors, lockers, glove box, boots, bonnets windows andload areas together with switching on any forced air ventilation

• inform our Examiner of your presence (observing social distancing rules)

• be prepared to move your vehicle onto pit/hoist if requested - Note - at this point theexaminer may check some items i.e. Lights, brake operation etc. with you in thevehicle

• ensure our Examiner has contact details if different from on this application form

• to leave the site during some of the examination - Note - you will be informed when toreturn

• on completion of the examination, the vehicle will be parked in a safe area away fromthe test lane

• upon collection, consider the benefit of venting the vehicle with all doors and windowsopen before driving away

b) Conditions that apply prior to examination :

In accordance with government advice, prior to examination and to minimise the risk of COVID 19 infection you need to confirm that the vehicle on this application will comply with the following at the time of examination:

• that the vehicle has been constructed or modified in compliance with all currentCOVID-19 Government and industry sector guidelines and, either;

• all vehicle surfaces have been or will be thoroughly and virally cleaned immediatelybefore the examination following current COVID-19 Government and industry sectorguidelines, or

• the vehicle has been or will be securely quarantined for at least 72 hours immediatelybefore the scheduled examination appointment.

You must sign the declaration below confirming that these conditions will be met at the time the vehicle is presented for examination. Note - At the time of examination the presenter must follow all directions given by the examiner. The presenter should wear appropriate PPE and maintain social distancing when not in control of the vehicle. The examiner will refuse to test the vehicle if these conditions are not met.

PSVA 1 (DVSA 0356) 4 Jan 2021

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4. DATA PROTECTION & SIGNATURE DETAILS

DATA PROTECTION – We collect, use and store your personal data so that we can process your application for a PSV accessibility certificate for a Non-DDA Approved Type.

We may share your personal data if we have a lawful reason. For example as part of a criminal investigation or to prevent fraud. Find out more at www.gov.uk/dvsa/privacy DECLARATION – I, the undersigned, declare that :

• The vehicle listed above will be built in accordance with the required standardscontained in the relevant COIF/DDA Regulations.

• The conditions listed at item 3 will be met at the time appointed for the examination.

I confirm that, as far as I know, all statements in this application are true.

Date : Signature :

Print Full Name :

Please Note : All ‘Declaration’ sections above must be completed. A typed ‘Signature’ is acceptable if sending your application electronically

5. PAYMENT DETAILSYou can pay the application fee by one of the following methods :

1. Cheques/postal orders - payable to the ‘Driver and Vehicle Standards Agency’(or ‘DVSA’) and only accepted with postal applications.

2. Credit/debit card - If you choose to pay by this method, then once yourapplication has been received, you will be contacted by email with instructions onhow to arrange your card payment.

3. Pre-funded account - If you are a regular user of the scheme this is the quickestmethod to use. For pre-funded accounts, the signatory on the application mustbe a delegate authorised to use the account. For more information on setting upa pre-funded account, go to www.gov.uk/dvsa

Details of the current fees can be found on our website at www.gov.uk/vehicleapproval or by telephoning our Customer Contact Centre on 0300 123 9000.

How are you paying for this application? (Please tick one box)

Cheque / Postal Order Payable to ‘Driver and Vehicle Standards Agency’ or ‘DVSA’ (only with postal applications). Credit / Debit Card Payment to be made after application is received. DVSA Pre-funded

Account PFA No. :

https://www.gov.uk/government/organisations/driver-and-vehicle-standards-agency/about/personal-information-charterhttps://www.gov.uk/government/publications/vosa-pre-funded-customer-account-application-formhttps://www.gov.uk/government/publications/individual-vehicle-approval-inspection-fees

PSVA 1 (DVSA 0356) 5 Jan 2021

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5. PAYMENT DETAILS (Cont.)

I hereby authorise the Driver and Vehicle Services Agency to take the amount stated below from my bank / pre-funded account in respect of my application.

£ .

Signature details : Please sign and print your name if you are either the card holder or PFA- delegate. A typed ‘Signature’ is acceptable if sending your form electronically.

Signature : Date :

Print Full Name :

ON COMPLETION

Please attach your fully completed application to the ‘Technical Application System’ (TAS) available on : www.gov.uk/dvsa

Should you experience problems accessing TAS, please try an alternative browser or contact DVSA Customer Contact Centre :

0300 123 9000

https://www.gov.uk/apply-vehicle-test-certificate-coach-bus

Company Name: Tel No: Registration Mark: Chassis VIN No: Chassis Make: Chassis Model: Body Make: Body Model: Which test location would you prefer: Is the vehicle is fitted with special features that affect stability: below: If YES please give type: Length cm: Height cm: Wheelbase: Date: Print Full Name: PFA No: Date_2: Print Full Name_2: Title: []Address 1: Customer Name: Address 2: Post Code: email: Schedule 1: OffSchedule 2: OffSchedule 3: OffAnnex VIII: OffReg 8: OffRestrained WC: OffUnrestrained WC: OffLift: OffPort Ramp: OffPower Ramp: OffAir Con: OffRetarder: OffAlloy: OffToilet: OffCrew Seat: OffDouble Glazing: OffScreen: OffCrew Comp: OffBefore Upper: After Upper: Before Lower: After Lower: Before Standing: After Standing: Before Wheelchairs: After Wheelchairs: Before Crew seats: After Crew seats: Weight: OffPay method: OffPound: Pence: Signature: Test Location URL: VTP5 URL: Personal info URL: PFA URL: Fees URL: