PD1 APPLICATION FOR PROFESSIONAL AANSOEK OM …
[Pages:3]PD1(12)(2005/11) REPUBLIC OF SOUTH AFRICA
REPUBLIEK VAN SUID-AFRIKA
PD1
APPLICATION FOR PROFESSIONAL
DRIVING PERMIT
Logo
(National Road Traffic Act, 1996)
AANSOEK OM PROFESSIONELE BESTUURSPERMIT
(Nasionale Padverkeerswet, 1996)
NOTE: When applying for a professional driving permit, it is essential that LET WEL: By die aansoek om `n professionele bestuurspermit, is dit
the applicant produces acceptable identification.
noodsaaklik dat die aansoeker aanvaarbare identifikasie voorl?.
LIST OF POSSIBLE TRANSACTIONS
APPLICATION FOR:
New/Professional driving permit Duplicate of professional driving permit
Mark with X Merk met X
Parts of the form to be completed Dele van die vorm
om in te vul
AB
D
A
CD
LYS VAN MOONTLIKE TRANSAKSIES
AANSOEK OM:
Nuwe/Professionele bestuurspermit Duplikaat van professionele bestuurspermit
NOTICE OF CHANGE OF Particulars of person (e.g. ID, name, address)
KENNISGEWING VAN VERANDERING VAN
A
CD
Besonderhede van persoon (bv. ID, naam, adres)
Professional driving permit
A
CD
Professionele bestuurspermit
PARTICULARS OF APPLICANT
A
Type of identification (mark with X)
traffic register no. RSA ID foreign ID verkeersregisternr. RSA ID buitelandse ID
BESONDERHEDE VAN AANSOEKER
Soort identifikasie (merk met X)
Identification number
Country of issue if foreign ID
Gender (mark with X)
male manlik
female vroulik
Photograph (laminate)
Foto (lamineer)
Identifikasienommer
Land van uitreiking indien buitelandse ID
Geslag (merk met X)
Surname
Initials and first names (not more than 3)
Date of birth
(initials/voorletters)
Official language of preference on driving licence (in addition to English) (mark with X)
E-mail address
none geen
(first names/voorname)
:
:
:
:
Y/J
MD
or Afrikaans Ndebele N/Sotho S/Sotho Swazi of Tsonga Tswana Venda Xhosa Zulu
Telephone number at home
Contact telephone number during day Facsimile number
Cellphone number
(code/kode)
(code/kode)
(code/kode)
(number/nommer) (number/nommer) (number/nommer)
Postal address
Van
Voorletters en voorname (hoogstens 3)
Geboortedatum
Amptelike taal van voorkeur op bestuurslisensie (benewens Engels)
(merk met X) E-pos adres Telefoonnommer by woning
Kontaktelefoonnommer bedags
Faksimileenommer
Selfoonnommer Posadres
Suburb City/Town
Street address
(postal code/poskode)
Voorstad Stad/Dorp
Straatadres
Suburb City/Town
(postal code/poskode)
Voorstad Stad/Dorp
Address where notice must be served (mark with X)
postal address street address
posadres
straatadres
Adres waar kennisgewing beteken moet word (merk met X)
CATEGORY OF PROFESSIONAL DRIVING PERMIT
Mark with a cross (X) the category(ies) for which a professional driving permit is required. Note that category D automatically includes category G.
B
KATEGORIE VAN PROFESSIONELE BESTUURSPERMIT
Trek `n kruis (X) teenoor die kategorie(?) waarvoor `n professionele bestuurspermit verlang word. Neem kennis dat kategorie D outomaties kategorie G insluit.
Category
State whether any previous application for a professional driving permit had been refused, and if so, where, when and reasons for refusal.
passengers dangerous goods passasiers P gevaarlike goedere D (21 years/jaar) (25 years/jaar)
or goods of goedere G
(18 years/jaar)
Kategorie
Meld of enige vorige aansoek om `n professionele bestuurspermit geweier is, en indien wel, waar, wanneer en redes vir weiering.
NOTICE OF CHANGE
Office of issue
Notice of (mark with X)
Theft/Loss reported
at
to Police
te
Date of change
C
KENNISGEWING VAN VERANDERING
Kantoor van uitreiking
theft
loss
destruction recovery
diefstal verlies vernietiging terugvinding
Reference no. (CAS no.) Verwysingsnr. (MAS nr.)
2:0 : Y/J
:
:
MD
Kennisgewing van (merk met X)
Diefstal/Verlies gerapporteer aan Polisie
Datum van verandering
DECLARATION
D
VERKLARING
I, the applicant, declare that:
Ek, die aansoeker, verklaar dat:
(a) I do not hold an issued learner's or driving licence or professional (a) ek nie die houer is van `n uitgereikte leerling- of bestuurslisensie of
driving permit which is at present cancelled or under suspension;
professionele bestuurspermit wat opgeskort of gekanselleer is nie;
(b) I am not for any other reason disqualified from holding a learner's or (b) ek nie om enige ander rede gediskwalifiseer is om `n leerling- of
driving licence or professional driving permit;
bestuurslisensie of professionele bestuurspermit te hou nie;
(c) I am medically fit for the purpose of driving a motor vehicle;
(d) this application is accompanied by none/three* photographs of myself;
(c) ek medies geskik is vir die doeleindes van die bestuur van `n motorvoertuig;
(d) hierdie aansoek vergesel word van geen/drie* foto's van myself;
(e) all the particulars furnished by me in this form are true and correct; and
(f) I realise that a false declaration is punishable with a fine or one year imprisonment or both.
Signature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Handtekening
Place . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Plek
Date
2:0 :
:
:
Datum
Y/J
MD
(e) alle besonderhede wat deur my op hierdie vorm verstrek is, waar en korrek is; en
(f) ek besef dat 'n vals verklaring strafbaar is met 'n boete of een jaar gevangenisstraf of beide.
FOR OFFICE USE ONLY - APPLICATION
NET VIR KANTOORGEBRUIK - AANSOEK
LIMITATIONS BEPERKINGS LICENCE CODE/ LISENSIEKODE
SNELLEN RATING/GRADERING
ORTHORATER VISUAL ACUITY GESIGSKERPTE
VISUAL FACULTY GESIGSVERMO?
with glasses/contact lenses met `n bril/kontaklense
without glasses/contact lenses sonder `n bril/kontaklense
DATE: DATUM:
A1 A B C1 C EB EC1 EC
FIELD OF VISION GESIGSVELD
LEFT LINKS
6/60 6/30 6/22 6/15 6/12 6/10 6/9 6/8 6/7 6/6 6/5 6/3 TEMPORAL TEMPORAAL
20/10 20/100 20/75 20/50 20/40 20/33 20/30 20/28 20/25 20/22 20/15 20/10 0
1 2 3 4 5 6 7 8 9 10 11 12
NASAL NASAAL
RIGHT REGS
1 2 3 4 5 6 7 8 9 10 11 12
any code only light motor vehicles disqualified enige kode slegs ligte motorvoertuie onbevoeg
Photos attached and proof of age Date of medical certificate (if any)
Visual faculty
yes no and yes no ja nee en ja nee
2:0 :
:
Y/J
M
any code enige kode
medically fit
medically unfit
:
medies geskik medies ongeskik
D
only light motor vehicles disqualified slegs ligte motorvoertuie onbevoeg
Foto's aangeheg en bewys van ouderdom Datum van mediese sertifikaat
(indien enige)
Gesigsvermo?
Finding
Infrastructure number, name and signature of examiner for driving licences
qualified not qualified bevoeg nie bevoeg nie
Bevinding
Infrastruktuurnommer, naam en handtekening van toetsbeampte vir bestuurslisensies
Name/Naam
Signature/Handtekening
DATA CAPTURING
Fees paid and receipt number for application
Date of application (effective date)
Name and signature of data capturing official
R ___________ and en
2:0 : Y/J
:
:
MD
Name/Naam
Signature/Handtekening
Date/Datum
DATAVASLEGGING
Gelde betaal en kwitansienommer vir aansoek
Datum van aansoek (effektiewe datum)
Date/Datum
Naam en handtekening van datavasleggingsbeampte
MUST BE COMPLETED BY TESTING CENTRE
Bar code and date of image scanning sheet/ live scan unit sheet
Reason for refusal
age
medical condition
ouderdom
mediese toestand
other (specify):
ander (spesifiseer):
MOET DEUR TOETSSENTRUM VOLTOOI WORD
and
en
2:0 :
Y/J
:
:
M
D
Strepieskode en datum van beeldvasleggingsvel/
lewendige vasleggingsvel
SAPS report SAPD verslag
recent MEC refusal onlangse LUR weiering
Rede vir weiering
AUTHORISATION BY EXAMINER FOR DRIVING LICENCES
MAGTIGING DEUR TOETSBEAMPTE VIR BESTUURSLISENSIES
Category(ies) of permit
not approved
or
nie goedgekeur nie of
or P D of G
Kategorie(?) van permit
Reason for refusal
age
medical condition
ouderdom
mediese toestand
other (specify):
ander (spesifiseer):
Date of authorisation/ refusal
Infrastructure number, name and signature of examiner for driving licences
2:0 : Y/J
SAPS report SAPD verslag
:
:
MD
MEC refusal LUR weiering
Rede vir weiering
Datum van magtiging/ weiering
Infrastruktuurnommer, naam en handtekening van toetsbeampte vir bestuurslisensies
Name and signature of data capturing official
Name/Naam Name/Naam
Signature/Handtekening Signature/Handtekening
Date/Datum Date/Datum
Naam en handtekening van datavasleggingsbeampte
................
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