MR205 Driver's Licence/Learner's Permit Application

DRIVER'S LICENCE/LEARNER'S PERMIT APPLICATION

MR205

02/21

WHAT THIS FORM IS USED FOR

The first time you apply for a South Australian Driver's Licence or Learner's Permit.

WHAT YOU WILL NEED

Evidence of your age, identity and your residence as outlined in point 2 below. Refer to MR583 Evidence of Identity brochure for more details. ? You may need to provide a medical or eyesight certificate, see point 5 below.

READ THIS INFORMATION FIRST

1. Y ou must be 16 or over to apply for a learner's permit.

2. Y ou must provide proof of your age, and also evidence of your identity. This information may be confirmed with the issuer or official record holder. Refer to Evidence of Identity brochure (MR583) for more information.

3. M ake sure that you give all information requested and answer all questions asked. You must personally sign the application.

4. E nsure that you give details of any disability or illness, including particulars of any medication. A medical certificate may be required.

5. Y ou may be requested to supply evidence that any illness or disability does not impair your ability to safely drive a motor vehicle.

6. D uring the term of a learner's permit or driver's licence, you must give in writing to the Registrar of Motor Vehicles, details of any disability or illness that may affect your fitness to drive a motor vehicle.

7. A ny learner's permit or driver's licence issued will not be valid if false or misleading details are given, or false evidence is supplied.

8. A ny learner's permit or driver's licence obtained when a person is disqualified or prevented from holding or obtaining a learner's permit or driver's licence is void and of no effect.

9. Interstate Licence must be surrendered before the issue of a South Australian Licence.

10. O verseas Licence must be surrendered before the issue of a South Australian Licence (an exemption may apply).

11. If a learner's permit, provisional licence, probationary licence or driver's licence is cancelled, either as a result of a disqualification imposed under the Motor Vehicles Act or any other Act, the unexpired portion of the permit/licence is forfeited. The Motor Vehicles Regulations specifically preclude the issue of a refund on the unexpired portion, where a permit/licence has been cancelled, and is essentially part of the penalty to encourage safe driving.

12. N o personal information will be disclosed except as is required or authorised by law.

ORIGINAL DOCUMENTS ONLY. PHOTOCOPIES ARE NOT ACCEPTABLE. ONCE SIGHTED, ORIGINAL DOCUMENTS ARE RETURNED TO THE APPLICANT. 1. YOUR DETAILS. Please write clearly using BLOCK LETTERS

CLIENT No. / SA Licence No.

This is either your Driver's Licence number or a number issued by Customer Services. If you do not know your number, please enquire.

SURNAME

GENDER M

F

X

GIVEN NAMES

DATE OF BIRTH

/

/

EMAIL ADDRESS

EYE COLOUR

HEIGHT

cm

HOME ADDRESS

SUBURB/TOWN

POSTAL ADDRESS (If different from above)

POSTCODE

PHONE

SUBURB/TOWN

POSTCODE

Are you of Aboriginal and/or Torres Strait Islander origin?*

NO

YES

Prefer not to say

*This information will be used for road safety statistical analysis only and will not be disclosed to any other authorities.

2. APPLICATION (Tick required boxes)

I HEREBY APPLY FOR

LEARNER'S PERMIT

DRIVER'S LICENCE

3. CLASS REQUIRED What class of Licence do you wish to apply for?

"C"

"R-Date"

"Other" (Please specify)............................................................................................................

4. OTHER PERMITS OR LICENCES

a) Do you currently hold, or have you ever been issued,

a driver's licence or permit in another State or country? YES

NO

If Yes, write the driver's licence number and where it was issued. (This driver's licence must be surrendered).

b) Have you previously held a driver's licence or learner's permit in South Australia YES

NO

PLEASE REFER TO BACK PAGE FOR FURTHER INFORMATION AND/OR REQUIREMENTS

For further information please go to: service..au ABN 92 366 288 135

When complete ? OFFICIAL: Sensitive//Medical in confidence

5. TRANSPORT CONCESSION. (Please tick whichever is applicable). NB: A concession is not available on LEARNER'S PERMITS.

I hold a Commonwealth Pensioner Entitlement Card I am a T.P.I. Ex-service person

My Concession Number is:

For your first totally incapacitated ex-service person concession, a letter of eligibility is required from the Department of Veterans' Affairs.

By claiming a pensioner concession you are giving consent for verification of your concession status with Centrelink/Department of Veterans' Affairs. If the concession details are confirmed, a reduced fee may apply.

6. ORGAN DONATION

ARE YOU PREPARED TO BECOME AN ORGAN DONOR?

If yes, an organ donor indicator will be shown on any photo learner's permit or driver's licence issued and will be recorded on the

YES

NO

department's database. Your details will then be provided to the `Australian Organ Donor Register' who may contact you for further details.

7. MEDICAL/IMPAIRMENTS

Do you have, or have you ever had any medical condition or suffered from any illness that may impair your competence to drive? YES

NO

E.g. cardiovascular disease, diabetes, epilepsy, hearing disorder, neurological disorder, psychiatric disorder, sleep disorder, blackouts,

vertigo, frequent fainting or dizziness, high blood pressure, use of or dependency on alcohol or illicit drugs. If you answer YES, please provide details.

Do you take medication for any medical condition that may affect your driving? If you answer YES, please provide details.

YES

NO

Do you have a vision or eye condition? E.g. cataracts, glaucoma, monocular vision, diplopia etc., If you answer YES, please provide details. YES

NO

Are you REQUIRED to wear glasses or corrective lenses at all times while driving? If you answer YES, please provide details.

Do you have any disabilities or impairments that may affect your driving? E.g. disabled arm, hand, leg or foot; loss of an arm, hand, leg or foot; disabled joint; muscular disorder; deafness or arthritis. If you answer YES, please provide details.

YES

NO

YES

NO

8. DISQUALIFICATIONS Are you DISQUALIFIED from holding or obtaining a licence or a permit or PROHIBITED or PREVENTED from driving in SOUTH AUSTRALIA or ELSEWHERE?

YES

NO

If yes, give details here

9. SIGN HERE - IT IS AN OFFENCE PUNISHABLE BY IMPRISONMENT TO MAKE A FALSE OR MISLEADING STATEMENT IN THIS APPLICATION. I HEREBY DECLARE THAT I HAVE TRUTHFULLY COMPLETED THIS FORM.

SIGNATURE

I consent to my information being checked with the document issuer or official record holder via third party systems for the purpose of confirming my identity.

DATE

/

/

OFFICE USE ONLY

TESTER'S CERTIFICATE

A. Proof of Identity, Age & Address ? Evidence of existence - photocopy attached

? Evidence of use of identity - photocopy attached

OR details of Credit/Debit card below

Application for a learner's permit - complete sections A. Application for a person licensed interstate - complete sections A & B. Application for a person licensed overseas - complete sections A & C. ("interstate" means other States and Territories of Australia)

B. Interstate Licence Transfer ? Photocopy of original Interstate Licence attached

? Has the licence been surrendered and receipt MR262 completed?

? Is a renewal being completed?

YES

NO

NO

Bank ................................................................................................................ Card type ............................................. Expiry Date ................. / ...............

C. Overseas Licence Conversion ? Photocopy of original Overseas Licence attached

? Evidence of residential address - photocopy attached ? At least one item showed signature and date of birth

? Has the licence been surrendered and receipt MR262 completed?

YES

NO

TESTER'S DECLARATION (not to be completed if applicant FAILS).

I certify that has passed the prescribed examination in the rules of the road.

STAMP OF TESTING STATION

TESTER'S NAME IN FULL

SIGNATURE

DATE

/

/

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