Government of Western Australia

Department of Transport Driver and Vehicle Services

Drivers Licence
Application Form

MDL 1

Tick appropriate box (P) NEW APPLICATION LEARNERS PERMIT RE-ISSUE LICENCE VARIATION
(Additional class or removal of condition)

INTERSTATE LICENCE LAPSED LICENCE EXTRAORDINARY LICENCE RE-ISSUE SURRENDERED

OVERSEAS LICENCE (Tick box below) NON- RECOGNISED COUNTRY RECOGNISED COUNTRY

REISSUE CANCELLED LICENCE LICENCE EXTENSION

Metropolitan or Regional T Extension

If you are applying for an F or T extension you must complete the following referee nomination. Referee Nomination: Referees must be persons who have known you for at least 4 years and who are not relatives. These referees may be contacted by staff from the Driver and Vehicle Services (DVS) Centre to provide information to assist DVS in determining your suitability to hold an F or T extension.

Referee One: Family Name: Occupation: Daytime telephone number: E-mail address: Given Name/s:

Referee Two: Family Name: Occupation: Daytime telephone number: E-mail address: Given Name/s:

I
Print applicants name

consent to officers from DVS contacting the above

referees in relation to my application for an F or T extension and conveying any information to them relevant to my application, including the details of any traffic or criminal convictions that may be recorded against me.

Signature :
Applicants signature

Date:

Witness:
Print witnesss name

Date:

Witness:

Witnesss signature

Site Code (if applicable):

LAST UPDATED: 11/01/2012

PARTICULARS OF APPLICANT Please use BLOCK LETTERS (Applicant to complete page 2 in full) FAMILY NAME: Residential Address Postal Address Date of Birth Home Phone Mobile Phone Email Work Phone Fax Given Names Post Code Post Code

PAGE 2

PERSONAL DETAILS (Not applicable for licence variation applicants) SEX (tick (P) box applicable) BUILD OCCUPATION Male Female HEIGHT EYE COLOUR COUNTRY OF BIRTH cm

HAIR COLOUR

DETAILS OF ANY LICENCE HELD (Including any previous WA licence held) STATE/ COUNTRY OF ISSUE LICENCE NUMBER CLASSES HELD PROVISIONAL EXPIRY DATE REQUIRED CLASS OF LICENCE Place (P) in boxes
Type of Vehicle Class Motor Car C Light Rigid LR Medium Rigid MR Heavy Rigid HR Heavy Combination HC MultiCombination MC R-N R-E R F T O Motorcycle Moped <=250cc Any motorcycle

*INITIAL ISSUE DATE

SEE PAGE 4

CURRENT EXPIRY DATE See page 4 for classifications of classes

Licence Extension Carrying Passengers for Reward Taxi Other

APPLICANT TO ANSWER ALL QUESTIONS - Your drivers licence may be suspended or cancelled for providing false or misleading information

QUESTION
Have you ever been refused a licence? Is your licence currently cancelled or suspended, or are you disqualified from holding or obtaining a licence? Has your licence ever been cancelled/ suspended or have you ever been disqualified from holding or obtaining a licence? Within WA or Interstate? Have you ever been convicted of a Traffic OR Criminal offence other than those stated above ANYWHERE in Australia or overseas?

YES NO

WHERE

WHEN AND WHY

MEDICAL QUESTIONS You are required by law to disclose any medical condition that may impair your ability to control a motor vehicle
Do you suffer from?
GIVE DETAILS EPILEPSY DIABETES FITS ARTHRITIS GIDDINESS HIGH/LOW BLOOD PRESSURE FAINTING HEART DISEASE SEIZURES DEPRESSION PHYSICAL/ MENTAL DISABILITY OTHER COMPLAINT OR DISEASE

Do you take Medication?

GIVE DETAILS

Yes

No

IMPORTANT: BEFORE SIGNING THIS DOCUMENT PLEASE READ INFORMATION ON PAGE 4

I certify that all information above is true and correct (penalty for false or misleading information) Signature of Applicant OFFICE USE ONLY Witness Officer Name: Signature of Officer: Date of Application

PAGE 3

OFFICE USE ONLY

NEW APPLICATION LEARNERS PERMIT RE-ISSUE LICENCE VARIATION
(ADDITIONAL CLASS OR REMOVAL OF CONDITION)

TO BE COMPLETED ON APPLICATION
(tick (P) box applicable
NON-RECOGNISED COUNTRY RE-ISSUE SURRENDERED RECOGNISED COUNTRY LICENCE EXTENSION LAPSED EXTRAORDINARY

INTERSTATE REISSUE CANCELLED

Western Australian Drivers LICENCE NUMBER LICENCE TYPE RESULT CTT PROVISIONAL EXPIRY DATE LICENCE CLASSES APPLIED FOR MOTORCYCLE ORAL ALCOHOL HEAVY VEHICLE

EXTENSION/ CONDITION
Licence Conditions/ Extension Class Conditions Class Nat. Conditions State Conditions

EYESIGHT RESULTS
Right eye

Left eye

Both eyes

Tested with Visual Aids Visual Aids to be worn whist driving S condition loaded/ removed

Yes Yes Yes

No No No

EYESIGHT TESTED BY Signature .............................................................................

LICENCE VARIATION (Additional class or removal of condition)

LICENCE NUMBER CLASSES RECOGNISED STATE/ COUNTRY OF ISSUE ........................................................................................... DATE OF ISSUE CURRENT EXPIRY DATE

OVERSEAS LICENCE CHECK LIST

Class conversion verified tick (P) box ........................................................................................................................................................................

Print Name ................................................................................................... Signature ......................................................................................................

PROOF OF PRIMARY & SECONDARY IDENTIFICATION CHECKLIST (tick (P) box applicable)
All documents must be ORIGINAL (Not Photocopies) Birth Certificate Visa or Immigration Documents Australian Citizenship Papers Western Australian Proof of Age Card (not 18+ Card) Australian Passport (Not expired by more than 2 years) Photographic Australian Drivers Licence (Not expired by more than two years) Overseas Passport - Current Proof of Residency Sighted/ Confirmed

Australian Identity Document (Not expired by more than 2 years) Signature Verified

PRIMARY IDENTIFICATION DOCUMENT NUMBER SECONDARY IDENTIFICATION SIGHTED (tick (P) box) LETTER OF CONSENT (Conditional licences only) Type of Document ......................................................................................... CONVICTION RECORDS CHECK (Lapsed Licence or EDL Renewal)
BRANCH/ SITE

Receipt Number ............................................................. Receipt Number .............................................................

DATE DATE
.............................................................................

PAGE 4

IMPORTANT
The information you supply on this form may be disclosed to other government agencies where provided for in legislation. The Director General of the Department of Transport also releases aggregated statistical information to third parties. However, your personal identifying information will not be released to these persons without your explicit consent.

DRIVER LICENCE CLASSES

CLASS VEHICLE DESCRIPTION Moped means a motorcycle that (a) has a propelling engine with an engine capacity not exceeding 50cc; and (b) is designed so as not to be capable of speed exceeding 60km/h, whether or not it is also capable of being propelled by pedalling, except that it does not include a power assisted pedal cycle. Any motorcycle with an engine capacity exceeding 100cc but not exceeding 250cc. Any motorcycle with or without side car attachment. Any motor carrier. A motor vehicle with a gross vehicle mass that is not greater than 4.5 tonnes and that is constructed or equipped to seat not more than 12 adults (including the driver). A motor vehicle that: has a gross vehicle mass greater than 4.5 tonnes but not greater than 8 tonnes; or seats more than 12 adults (including the driver) and has a gross vehicle mass not greater than 8 tonnes. EXPERIENCE CRITERIA FOR CLASSES No experience required (minimum age 16 years). Applicant can apply for Learners Permit at age of 15 years and 6 months.

R-N Moped

R-E Motorcycle R Motorcycle C Car LR Light Rigid

No experience required (minimum age 17 years). Must have held an R-E licence for at least one year. No experience required (minimum age 17 years).

Must have held a C (Car) licence for at least one year.

A motor vehicle that has 2 axles and a gross vehicle mass MR Medium Rigid greater than 8 tonnes

Must have held a C (Car) licence for at least one year. Must have held: C (Car) licence for at least two years; or LR or MR licence for at least one year. Must have held: C (Car) licence for at least three years; and MR or HR licence for at least one year.

HR Heavy Rigid HC Heavy Combination MC MultiCombination

A motor vehicle that has 3 or more axles and a gross vehicle mass greater than 8 tonnes A prime mover to which is attached a single semi trailer plus any unladen converter dolly; or A rigid motor vehicle to which is attached a trailer that has a gross vehicle mass greater than 9 tonnes plus any unladen converter dolly Any Heavy Combination unit towing one or more additional trailers each having a gross vehicle mass greater than 9 tonnes

Must have held: C (Car) licence for at least three years; and HR or HC licence for at least one year.

LICENCE EXTENSION T Extension Taxis and Small Charter Vehicles (Taxi) Has reached the age of 20 years. Has held a drivers licence for a period of 3 years and is not a provisional driver Has provided details of 2 referees on the front page of this form. Is mentally and physically fit to drive a motor vehicle for the purposes of carrying passengers for reward. Has successfully completed a training course or test approved by the Director General. F Extension Buses and Small Charter Vehicles (Not Taxis) Has reached the age of 21. Has held a drivers licence for a period of 4 years and is not a provisional driver. Has provided details of 2 referees on the front page of this form. Is mentally and physically fit to drive a motor vehicle for the purposes of carrying passengers for reward.

Initial Issue Date Is the date your drivers licence was first issued to you (not the current date of issue or previous renewal date)