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Fillable Printable Application for a Dangerous Goods Driver Licence - Western Australia

Fillable Printable Application for a Dangerous Goods Driver Licence - Western Australia

Application for a Dangerous Goods Driver Licence - Western Australia

Application for a Dangerous Goods Driver Licence - Western Australia

Page | 1 Application for a dangerous goods driver licence DGDL REV3
Application no. (office use only)
Application for a dangerous goods driver licence
Dangerous Goods Safety Act 2004
Dangerous Goods Safety (Road and Rail Transport of Non-explosives) Regulations 2007
ABN: 69 410 335 356
Refer to Dangerous goods driver licence – general information for guidance in completing this application.
1. Type of application (please tick applicable)
(N) and (U) denotes requirements for application type
New application (N) Upgrade to licence (U)
Licence number DDB
2. Applicant details (applicants must be at least 18 years of age) (N) (U)
Family name Given names
Date of birth DD / MM / YYYY Email
Phone no. (day) Mobile phone no.
Motor driver’s licence (MDL) State Expiry date DD / MM / YYYY
Residential address (must be a Western Australian address)
Unit no. Street no. Lot no. Street name Type e.g. St, Rd
Town / suburb State WA Postcode
Postal address (if different to residential)
Unit no. Street no. Lot no. Street name Type e.g. St, Rd
PO Box no. Town / suburb State Postcode
The following supporting evidence must be lodged with your application (if required)
3. Photograph (N)
A colour passport photograph with your signature and name printed on the back.
The photo must have been taken not more than six months before the day the application is lodged.
4. Motor driver’s licence (N)
Legible colour copy of both sides of your current MDL.
5. Medical certificate (N)
The original medical certificate assessed against the standards in Assessing Fitness to Drive for Commercial and Private Vehicle
Drivers.
The medical certificate must be dated not more than six months before the day the application is lodged.
6. Western Australian (WA) driving record (N)
An original National Police Certificate and original Certified Copy of Traffic Infringements, regardless of whether you have, or have
not been issued with a WA MDL.
Dated not more than six months before the day the application is lodged.
Page | 2 Application for a dangerous goods driver licence DGDL REV3
7. Other WA driving record (N)
In the last 5 years, if you have been served with any of the following notice(s), lodge the original notice(s) with your application.
Note: Failure to provide these documents may delay the issuing of the licence.
Excessive demerit points
Grant of good behaviour
Disqualification, suspension or cancellation of MDL
Election of good behaviour
Breach of good behaviour
8. Non-WA driving record (N)
In the last 5 years, where you have been issued a MDL in another Australian State or Territory and/or New Zealand, your driving
record from these places is required.
Dated not more than six months before the day the application is lodged.
9. Other non-WA driving record (N)
In the last 5 years, where you have not been issued a MDL, but have incurred an infringement, loss of demerit points or a
conviction in another Australian State or Territory, and/or New Zealand, your driving record from these places is required.
Dated not more than six months before the day the application is lodged.
10. Competency (N) (U)
The original Statement of Attainment or Certificate of Competency certificate.
Dated not more than six months before the day the application is lodged.
11. Consent and declaration (N) (U)
For the purpose of deciding this application, I consent to the Department of Mines and Petroleum:
Accessing any of my driver licence records held by any driver licensing authority in Australia, or New Zealand; and
Contacting the certifying medical practitioner or other medical professionals in regard to information provided on, or with the
medical certificate.
I declare the information provided in this application and the documents provided in support of it, are true and correct.
I understand that providing false or misleading information in an application is an offence.
Signature Date
DD / MM / YYYY
12. Payment and contact details (N)
Payment type (please tick
)
Credit card Cheque Money order
Cheque and money orders made payable to: Department of Mines and Petroleum
Payments will not be accepted by either Electronic Bank Transfer (EFT) or a direct bank debit.
…………………………………………………………………………………………………………………………………………………………
Complete this section if paying by credit card
Card number Expiry date DD / MM / YYYY
_ _ _ _ / _ _ _ _ / _ _ _ _ / _ _ _ _
Card type
Mastercard Visa
Card holder’s name (please
print)
Signature of card holder
Cardholder’s phone number
Amount $
Mailing address Business address
Resources Safety 1 Adelaide Terrace
Department of Mines and Petroleum EAST PERTH
100 Plain St Business hours: 8.30 am – 4.30 pm
EAST PERTH WA 6004 Ph: 9358 8001 Email: rsdcustom[email protected]p.wa.gov.au
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