Fillable Printable Driver Licence Application - Queensland

Driver Licence Application - Queensland

Queensland driver licence renewal kit

General notice for applicants temporarily residing interstate or overseas

This kit is provided by the Department of Transport and Main Roads (TMR) to assist you in renewing, upgrading or

re-applying of your Queensland (Qld) driver licence if you are temporarily residing interstate or overseas.

Please note you can not use this kit if your licence is expired by more than five years or if your licence is currently

cancelled or you are currently disqualified from holding or obtaining a driver licence in Australia or another country.

If your licence has expired and you do not wish to drive while you are absent from Qld, you may renew the licence up to five

years after the date of expiry before being required to undertake another written and practical (on road) driving test. However,

if you need to drive, you should return your completed application and relevant documentation promptly and allow for

overseas mail delays. It is important that all correct documentation is received by TMR at least two weeks before your licence

expires to enable your driver licence to be renewed prior to the expiry date.

Licensing requirements for temporary residents in other states and countries may differ to those in Qld. On taking up

temporary residency it is recommended that you contact the appropriate Licensing Authority to ensure that you are aware of

and continue to meet local requirements. You must also contact the Licensing Authority if your residency status changes, for

example, if you do not intend to return to Qld to live.

New Queensland driver licence

A new Qld driver licence is being introduced to replace the existing laminated driver licence. The move to a credit card sized

plastic product, embedded with a chip, will improve the licence durability and security. As your driver licence is due for

renewal, you may be eligible to apply for the new Qld driver licence.

If the photographs given by you do not meet the minimum standard for the issue of the new Qld driver licence, you may be

issued a laminate driver licence. To upgrade to the new Qld driver licence you will need to apply in person when you return to

Qld.

You may choose to renew your licence for a period of one to five years. Following are the new Qld driver licence fees –

1 year is A$64.20, 2 years is A$89.50, 3 years is A$110.75, 4 years is A$128.15 or 5 years is A$143.75.

Note: Fees increase 1 July each year. Current driver licensing fees can be found on the department’s website

Please read the following Application Requirements carefully and use the Application Checklist to confirm that all

required documentation has been provided to ensure that your application can be processed.

Application Requirements

Driver Licence Application/Renewal (form F3000)

You must complete the Driver Licence Application/Renewal (form F3000). This form must be signed in the presence of an

Approved Witness. The Approved Witness must then sign and complete the Authorising person’s declaration on the form.

(Refer to Verification of Identity – Approved Witnesses list.)

A Qld residential address must be nominated on the application form F3000. (Note: If a postal address has not been

nominated on this form or the Specimen Signature (form F2127) your new card will be sent to your residential address.)

Specimen Signature (form F2127)

A Specimen Signature (form F2127) must be submitted with your application. Please ensure that all sections of this form are

completed, including both signature boxes. You must clearly print your name and the address where you want your new

driver licence posted to. This postal address will be applied to your driver licence record and used for licence and vehicle

registration correspondence until otherwise advised by you. You will need to notify the department of a change to your postal

address on your return to Qld. You may do so by calling 13 23 80 or visiting Services online at www.tmr.qld.gov.au.

Temporary Residence Statement Interstate or Overseas (form F2350)

A Temporary Residence Statement Interstate or Overseas (form F2350) must be completed and submitted with your

application. The declaration must be signed by you in the presence of an Approved Witness. The Approved Witness must

then sign and complete the Authorising person’s declaration on the form. (Refer to Verification of Identity – Approved

Witnesses list.)

Medical Certificate for Motor Vehicle Driver (form F3712)

A Medical Certificate for Motor Vehicle Driver (form F3712) is required if you have a mental or physical incapacity that may

adversely affect your ability to drive safely and/or you are 75 years of age or older. If this applies to you then you must:

•

complete Part One of the Medical Certificate for Motor Vehicle Driver (form F3712).

•

complete the Private and Commercial Vehicle Driver's Health Assessment (form F3195) and give the form to the doctor

assessing your fitness to drive.

The doctor assessing your fitness to drive must complete Part Two of the Medical Certificate for Motor Vehicle Driver (form

F3712).

Department of Transport and Main Roads, General notice for applicants temporarily residing interstate or overseas – renewal, July 2012

www.tmr.qld.gov.au

Department of Transport and Main Roads, General notice for applicants temporarily residing interstate or overseas – renewal, July 2012

Photographs

You are required to provide two (2) identical colour photographs that meet the following format:

•

Passport quality. Note: Automatic machine photographs are not acceptable (e.g. from a photo booth)

•

35mm wide x 45mm long in size and must not be more than 6 months old

•

Printed on high-quality paper and using high resolution (preferably 600dpi or higher)

•

Must not be manipulated, for example, by removing spots or softening lines

•

Signed and endorsed on the reverse side by an Approved Witness. Note: One (1) of these photographs must be signed

and endorsed on the back with the words: “I certify this is a true photograph of (the applicant) in my presence”.

The following guideline will help you provide suitable photographs so that your application is not delayed by having

to submit new photographs that meet the required criteria.

The photographs must:

•

show natural skin tones and have appropriate brightness and contrast, no flash reflections and no red eye. Note: Do

not remove red eye in post production software

•

show you with a neutral expression and mouth closed

•

have a plain, light coloured background (e.g. white, cream or pale blue)

•

show you looking directly at the camera

•

show you with no hair across your eyes

•

show both edges of your face clearly

•

have a full front view of head and shoulders and not show you looking over one shoulder (portrait style) or with head

tilted.

Glasses or sunglasses must be removed for the photograph, even if normally worn for driving. Note: Glasses or eye patches

may be accepted if a Medical Certificate for Motor Vehicle Driver (form F3712) states that eye protection is required to be

worn by you as protection from the effects of flash photography.

Head coverings and hats are not permitted, except for religious reasons, in which case facial features from bottom of chin to

top of forehead and both edges of your face must be clearly shown.

Note: If you are an existing laminate licence holder and the photograph does not meet the standard for the grant of the new

Qld driver licence, you may be granted a laminate licence.

Verification of Identity – Approved Witnesses

You will need to sign the Driver Licence Application/Renewal (form F3000) and the Temporary Residence Statement

Interstate or Overseas (form F2350) in the presence of a witness, or local equivalent, who is either a:

•

Doctor

•

Police Officer

•

Consular or Ambassadorial Officer

•

Solicitor, Barrister or Judge

•

Justice of the Peace or a Commissioner for Declarations

•

Notary Public or a person authorised by law to witness & sign declarations

The witness must sign and print their full name, position title/designation and contact details (including office stamp).

Note: You may have to pay a fee to have the documents witnessed. All documents are to be witnessed in English or have

an English translation.

Evidence of Identity Requirements

You are required to provide a photocopy of your current Qld driver licence, industry authority, marine licence indicator or

adult proof of age card document which has been signed and endorsed by an Approved Witness. The photocopy must be

endorsed with the words “I have sighted the original document and certify this to be a true copy of the original”.

If you can not provide a witnessed photocopy of your Qld driver licence, industry authority, marine licence indicator or adult

proof of age card, you must provide witnessed photocopies of three (3) evidence of identity (EOI) documents. (Note: Please

refer to the Verification of Identity – Approved Witnesses list.) These documents must include one category A and one

category B document. The third document may be from either category. One of these documents must include your

signature. If your Qld residential address is not shown on any EOI documents provided, you must also show an evidence of

Qld residential address document.

If you have changed your name or the details of your name are different on the documents provided, you must show a

change of name document from the relevant Australian Registrar of Births, Deaths or Marriages (BDM). Please refer to the

attached Evidence of Identity Requirements (form F4362) for more information.

Department of Transport and Main Roads, General notice for applicants temporarily residing interstate or overseas – renewal, July 2012

Upgrading from a Provisional P1 type licence to a Provisional P2 type or open licence

To apply to upgrade your provisional P1 type licence to a provisional P2 type or open licence you must:

•

successfully complete the Hazard Perception Test online by visiting www.tmr.qld.gov.au

•

pay the Hazard Perception Test fee.

•

hold your provisional P1 type licence for a minimum period of one year. Note: Periods of licence suspension,

cancellation or disqualification will not count towards the minimum period.

Driver Licence Application Fee

If you are interstate the fee is to be paid by money order or cheque. If you are overseas, the fee must be paid by a personal

or bank cheque in Australian Dollars (AUD) and be from an Australian affiliated bank. The cheque or money order must be

made payable to Department of Transport and Main Roads (cash is unacceptable). To ensure that the driver licence renewal

fee amount is correct, visit www.tmr.qld.gov.au.

Alternatively, the fee may be paid directly into your account, which is linked to your driver licence number, at a Department of

Transport and Main Roads Customer Service Centre, Queensland Government Agency program office or driver licence

issuing police station.

Note: If you choose to have someone pay the fee directly into your account at a driver licensing issuing centre, the fee must

be paid prior to sending the completed application to TMR.

Completed applications should be forwarded to:

The Manager

Department of Transport and Main Roads

Dalby Customer Service Centre

PO Box 767

Dalby Qld 4405

If your application is approved, your new driver licence will be sent to the mailing address nominated by you.

Please contact the department by telephone (07) 4660 6500 or facsimile (07) 4662 5274 if you have any questions about the

processing of your Driver Licence Application/Renewal.

Application Checklist

Use this checklist to ensure that you have provided the required documentation. Incomplete

applications will not be processed.

□

Driver Licence Application / Renewal (form F3000) completed and witnessed as directed

□

Specimen Signature (form F2127) completed as directed

□

Temporary Residence Statement Interstate or Overseas (form F2350) completed and

witnessed as directed

□

Medical Certificate for Motor Vehicle Driver (form F3712) completed (if required)

□ Two (2) identical colour photographs, one of which is signed and endorsed as directed

□ Witnessed photocopy of your Queensland driver licence (current or expired less than two

years) or alternative documents as per Evidence of Identity Requirements for Individuals

(form F4362)

□ Applicable fee attached (or Receipt Number if payment has been made directly into your

account held with the department)

Page 1 of 2 CFA Form F3000 ES V01 Feb 2012

Driver Licence Application/Renewal

(Learner, P1, P2, P type and Open Licence)

Transport Operations (Road Use Management) Act 1995

Continued over page...

This form is to be used if you are applying for the grant or renewal of a Queensland

(Qld) driver licence. You are not eligible to make this application if your licence

is suspended or cancelled or while you are disqualified from holding or obtaining

a driver licence in any Australian state, territory or any other country.

If you currently hold a Qld marine licence granted to you under the Transport

Operations (Marine Safety) Act 1994, a marine licence indicator code will be

included on your Qld driver licence.

Personal Identification Number (PIN) and Shared Secrets

To record your PIN or Shared Secrets on your driver licence, please complete the

Personal Identification Number and Shared Secrets Application (form F4748).

Evidence of Identity (EOI) Requirements

You must give evidence of your identity. You may do so by presenting your Qld

driver licence. If you are unable to present your driver licence, your Qld industry

authority, marine licence indicator or adult proof of age (APA) card may be

accepted (conditions apply). If you are unable to present any of these documents

you will need to present three (3) EOI documents. These documents must include

at least one Category A document and one Category B document. The third

document may be from either category however, one of these documents must

include your signature. If your Qld residential address is not shown on any EOI

documents provided, you must also show an evidence of Qld residential address

document. All documents must be current or expired less than 2 years. All

documents must be original documents. Photocopies and certified copies of

original documents are not acceptable. Please refer to the Evidence of Identity

Requir

ements for Individuals (form F4362) or the Department of Transport and

Main Roads (the department) website www.tmr.qld.gov.au for a full list of EOI,

evidence of Qld residential address and change of name documents.

Change of Name Requirements

If you have changed your name or the details of your name are different on the

documents provided, you must show a change of name document from the relevant

Australian Registrar of Births, Deaths and Marriages (BDM).

Digital Photo

You may be required to allow the taking of a digital photo to confirm your

connection to the most recent digital photo kept by the department or to renew

the latest digital photo.

Medical Condition Reporting

If you are applying for the grant or renewal of a driver licence, you are required

by law to notify the department if you have a medical condition. A medical

condition means a mental or physical incapacity that is likely to adversely affect

your ability to drive safely. You may be required to give a medical certificate

providing information about your medical condition to allow a decision to be

made as to your eligibility to hold, or to continue to hold, a driver licence. A

medical certificate means a Medical Certificate for Motor Vehicle Driver (form

F3712) that has been completed by your treating health professional (treating

doctor). If you have a medical condition, your treating doctor is required to assess

your medical fitness to drive according to either the private vehicle driver

standards or the commercial vehicle driver standards in accordance with the

National Medical Standards as set out in the Assessing Fitness to Drive 2003

guidelines.

Please Note: When making an appointment, you should tell your health professional

why you are making the appointment because this kind of medical assessment

may take longer than a standard consultation.

Organ and tissue donation

Your decision about organ and tissue donor intention is no longer recorded on

your Qld driver licence. The Australian Organ Donor Register is now the only

place for you to record your legal decision to donate organs and tissue for

transplantation. For more information about registering your decision about organ

and tissue donation call 1800 777 203 or visit www.tmr.qld.gov.au

Postal address (if same as residential, write AS ABOVE ) 

Daytime contact phone number Date of birth

Town and country of birth

1. Personal details

Family name (Please PRINT)

Given name/s

Residential address

Male

Female

/ /

Day Month Year

Can you show your Qld driver licence, industry authority,

marine licence indicator or APA card?

Yes

You are required to show three (3) EOI documents and one (1) evidence

of Qld residential address document (refer to Evidence of Identity

Requirements for Individuals F4362). Please provide details of your

documents.

Category A (Please PRINT)

Category B (Please PRINT)

Evidence of Qld residency address (Please PRINT)

Is your name different to the name/s on your EOI documents?

Yes

You are required to show a change of name document (refer to Evidence

of Identity Requirements for Individuals F4362). Please provide details

of your documents.

Do you have a driver licence issued to you by another

Australian state, territory or country?

Yes Driver licence number (if known) Effective date

Note:

If you have a driver licence issued to you by another Australian state or territory,

you are not eligible for the grant of a Qld driver licence if you do not surrender

this driver licence to the department.

/ /

Day Month Year

Licence type

State/Territory/Country of issue

Category A or B (Please PRINT)

Change of name (Please PRINT)

Licence/authority/reference number

Document number

(e.g. X0100011)

Document type

(e.g. Qld BDM birth certificate)

Document number (do not

give credit/debit card number)

Document type

(e.g. CBA credit card)

Document numberDocument type

Issue date

(e.g. 10/06/2010)

Document type

(e.g. Telephone account)

Registration year

(e.g. 2010)

Document type (

e.g. Qld BDM

issued Marriage Certificate)

Document number

(e.g. 001000)

Expiry date

/ /

Day Month Year

Have you ever held a Qld driver licence in another name?

Yes

Driver licence number

(if known) Expiry date

Eye colour Height Hair colour Complexion

cms

/ /

Day Month Year

Family name (Please PRINT) Given name/s

Licence class/es

What type of licence are you applying for?

Learner licence P1 type licence Open licence

P type licence P2 type licence

Postcode

No Yes

18.

*Note 1: You and your treating doctor must also complete the Private and Commercial Vehicle

Driver s Health Assessment (form F3195) if you hold or are applying for a licence to

drive any of the following vehicles:

 a vehicle that is more than 8t GVM (class MR, HR, HC, MC, UD);

 a public passenger vehicle (e.g. taxi, limousine, bus);

 a vehicle carrying dangerous goods.

A specialist report may also be required to be given to your treating doctor.

Do you have any other medical condition that is likely to

adversely affect your ability to drive safely?

Medical certificate (form F3712)

is required (see Note 1*)

Applicant s declaration

Sign only in the presence of a departmental person.

I declare that I have read all the answers I have given to the questions in this application

and that the answers given by me are complete, true and correct in every detail. I understand

that if I have stated anything in this application that is false or misleading, the driver

licence granted to me as a result of this application will be absolutely void and have no

legal effect whatsoever. I understand that I may be prosecuted for giving or stating any

false or misleading information or documents. I also declare that the information I have

given about my medical fitness to drive, is to the best of my knowledge, true and correct.

I consent to the department taking, keeping and using my personal information, documents,

digital photo and digitised signature for the purposes associated with my application for

a Qld driver licence. I consent to the department verifying my EOI information provided

by me with the issuing authority or their agencies.

Additional declaration by Interstate licence holders

I understand that by signing this declaration I agree to the surrender of my interstate driver

licence.

Applicant s signature Date

It is an offence under the Transport Operations (Road Use Management) Act 1995 to

state anything or give a document to an authorised person if you know it contains false

or misleading information. The maximum penalty may be more than $6000.

/ /

Day Month Year

Were glasses or contact lenses worn for

the test?

Office Use Only

Practical driving test results

Class tested Code/condition (if any)

Passed Failed

Examiner s signature Date

Day Month Year

/ /

Examiner s number Report number

Eyesight test (if required)

NoYes

Tick where applicable

Give refusal letter

Comments

Authorising person s declaration

Authorising person s name

Authorising person s signature Date

Day Month Year

/ /

Office Stamp

Right Left Both

Application not approved

6 / 6 / 6 /

I declare that I have witnessed the applicant s signature. I am satisfied that the signature accords

satisfactorily with the signature appearing on the EOI document/s. I also declare that I have

sighted the EOI, Evidence of Qld residency and change of name documents as required.

Privacy Statement: The Department of Transport and Main Roads (the department) provides this form

under the Transport Operations (Road Use Management) Act 1995 (the Act) so that you may apply for a Qld

driver licence. The information, documents and digital photo collected for the purpose of this application

may be accessible by authorised departmental persons and some of this information may be disclosed to the

Qld Police Service as allowed under the Act or otherwise authorised under the Police Powers and Responsibilities

Act 2000. The department s licence production contractor will have controlled access to your information,

digitised signature and digital photo to make your licence. The department will not disclose your information,

documents, digitised signature or digital photo to any other third parties without your consent unless authorised

by law.

19.

Registered operator s authorisation for test vehicle

I authorise any Driving Examiner employed by the department or any Police

Officer, to drive my motor vehicle during or in connection with any driving test

undertaken in my vehicle, if required.

20.

Registered operator s signature Date

/ /

Day Month Year

Vehicle registration number

#Note 2: A Medical Certificate (form F3712) is required if your licence has a condition code

M and your doctor has indicated that you now meet the medical criteria for an

unconditional licence.

Application approved1:1 match performed

(See Note 2#)

Applicant s EOI confirmed

Applicant s details confirmed

in TRAILS/TICA

9. Are you currently or have you recently been disqualified

from holding or obtaining a Qld marine licence by an order

of an Australian or overseas court?

Length of disqualification

Yes State/Territory/Country

10. Are you currently or have you recently been disqualified

from holding or obtaining a driver licence by an order of

an Australian or overseas court?

Length of disqualification

Yes State/Territory/Country

8. Do you currently have a Qld marine licence?

Yes What marine licence do you hold?

Recreational marine driver licence

Personal watercraft licence PWCL

RMDL

14. Do you need to wear glasses/contact lenses for driving?

No Yes S condition will be shown on your licence

No Yes

Note: An Optometrist or Ophthalmologist report may also be required to be given to

your treating doctor.

Medical certificate (form F3712) is required

16.

No Yes How is your diabetes controlled?

Diet only

Insulin or other

glucose-lowering agent

Medical certificate (form F3712) is

not required

Medical certificate (form F3712) is

required (see Note 1*)

Do you have diabetes?

13. Is your driver licence currently suspended for any of

the following reasons:

State/Territory/Country Period

No YesSpeeding offence?

The accumulation of

demerit points?

Unpaid fines? No Yes

No Yes

Give details below

Any other reasons? No Yes

Heavy

Combination

What class/es of driver licence are you applying for?

Car

Light Rigid

Multi

Combination

Medium Rigid

Learner Approved

Motorbike

Heavy Rigid

*Specially Constructed

Vehicle

MC UD

*Note:

If you already hold a class LR licence or a higher class, you may not need a class

UD licence.

For information about Learner Approved Motorbikes visit

www.tmr.qld.gov.au.

11.Have you been granted a court order for any of the following

reasons? (Please show your court order)

12. Has your licence been cancelled for any other reason?

Yes Reason for cancellation

PeriodState/Territory/Country

15. Do you have any other vision or eye disorders?

(a) a drink or drug driving conviction

Yes Code X1 will be shown on your driver licence.

(b) Special Hardship Order (SHO)

Yes Code X3 will be shown on your driver licence.

Yes Code X4 will be shown on your driver licence.

No Yes

Medical certificate (form F3712) is required (see Note 1*)

17.

Yes

Have you been diagnosed with epilepsy or experienced

a seizure at any time?

Go to 18

Have you experienced a seizure or been required to take

anti-epileptic medication after the age of 11?

Page 2 of 2 CFA Form F3000 ES V01 Feb 2012

Specimen Signature

Adult Proof of Age Card Act 2008; Tow Truck act 1973; Transport Operations (Marine Safety) Act 1994;

Transport Operations (Passenger Transport) Act 1994; Transport Operations (Road Use Management) Act 1995

SSA Multimedia Services Form F2127 ES V01 Dec 2010

Contact Name:

Contact Telephone Number:

Contact Fax Number:

Email Address:

Instructions for printing this form: To ensure that the correct size is obtained for digital imaging of your signature, plain white A4

paper must be used. Please ensure both signature boxes are completed.

1. Specimen signature

2. Postal address label

(ONLY for driver licence holders who are temporarily interstate or overseas)

For the renewal or replacement of your Queensland driver licence, clearly PRINT your name and the address where you want your

new driver licence

posted to:

3. Contact details

Privacy Statement: The Department of Transport and Main Roads (the department) provides this form under the Transport Operations (Road Use Management) Act 1995, Tow Truck

Act 1973, Transport Operations (Passenger Transport) Act 1994, Transport Operations (Marine Safety) Act 1994 and the Adult Proof of Age Card Act 2008 so that you may provide a

specimen of your signature for inclusion on your new Queensland driver licence, industry authority, marine licence indicator or adult proof of age card. The information or signature

collected on this form will be accessible by authorised departmental persons and some of this information may be disclosed to the Queensland Police Service and interstate driver licensing

authorities as allowed under the Acts. The department will not disclose your personal information or signature to any other third parties without your consent unless authorised or required

by law.

FOLD HERE

To assist with the processing of your application, please supply contact details for any queries about your application.

Name:

Building Name:

Suburb/Town:

Postcode:

Country:

Floor:

Unit/Flat No: Street No:

Street Name:

Please sign using a black pen so that your signature

is WITHIN the white space provided

Specimen Signature

Please sign using a black pen so that your signature

is WITHIN the white space provided

Specimen Signature

Temporary Residence Statement

Interstate or Overseas

SSA Multimedia Services Form F2350 ES V01 Jan 2010

Note - The supply of false or misleading information constitutes an offence under the

Transport Operations (Road Use Management) Act 1995

and will result in a driver licence being declared null and void.

Statement

Family and given name/s

Queensland residential address

Postcode

in the State of Queensland, do solemnly and sincerely declare that I am temporarily residing at

the reason being

I intend to be returning to Queensland on or about

/ /

Declaration

I declare the above information is true and correct in every detail.

Applicant s signature

/ /

Date

Witness s signature

/ /

Date

Witness s name (please PRINT)

Privacy statement: The Department of Transport and Main Roads (the department) provides this form under the Transport Operations (Road Use Management)

Act 1995 so that you may declare that, at the time of renewing your driver licence, you are only residing temporarily outside Queensland. The information collected

on this form is accessible by authorised departmental persons and some of this information may be disclosed to the Queensland Police Service and interstate driver

licensing authorities. The department will not disclose your personal details to any other third parties without your consent unless required by law.

The witness must be a Police Officer, Justice of the Peace,

Commissioner of Declarations or a Medical Practitioner.

Medical Certificate for Motor Vehicle Driver

Transport Operations (Passenger Transport) Act 1994, Tow Truck Act 1973,

Transport Operations (Road Use Management) Act 1995

Form F3712 V01 Mar 2012 Corporate Forms Area Page 1 of 4

This form has been provided so that your treating doctor, optometrist or ophthalmologist (if required) may provide their opinion as to whether or not you meet the medical

and/or visual standard for a driver licence for the class/es of licence you are applying for, renewing or currently hold.

Part 1 of this form should be completed by you before giving the form to your treating doctor;

Part 2 should be completed by your treating doctor after considering any report from a specialist, optometrist or ophthalmologist (if required);

Part 3 should be completed by the treating optometrist/ophthalmologist if the vision or eye disorder is not rectified by wearing glasses or contact lenses;

Part 4 Medical Assessment Information provides helpful information about this form.

This medical assessment should be conducted in accordance with the national medical standards (Commercial and Private Vehicle Drivers) Assessing Fitness to Drive

2012 (AFTD). This publication is available from the Department of Transport and Main Roads (the department) or the Austroads website www.austroads.com.au. For

more information about medical conditions and medications, please refer to the department s website www.tmr.qld.gov.au.

Postcode

Male Female

Family name

Given name/s

Residential address

Date of birth

/ /

Licence number (if known)

State/ Territory/ Country of issue

Part 1 Personal Details

(to be completed by the driver)

1. Personal details

2. What type of licence are you applying for or currently hold?

3. What class/es of licence are you applying for or currently

hold?

Motorbike (RE or R)

Car (C)

Light Rigid (LR)

Medium Rigid (MR)

Heavy Rigid (HR)

Heavy Combination (HC)

Multi-Combination (MC)

Specially Constructed Vehicle (UD)

4. Do you drive, or intend to drive

a vehicle with a GVM of more than 8t (class MR, HR, HC, MC, UD)?

5. Do you need to wear glasses or contact lenses for driving?

No Yes

7. Driver s declaration:

I understand that if I have stated anything on this form that is false or misleading

the driver licence granted to me will be absolutely void and have no legal effect

whatsoever.

I understand that I may be prosecuted for giving or stating any false or misleading

information in relation to this form.

I declare that the information given to my treating doctor, optometrist or

ophthalmologist (if required) about my medical condition is, to the best of my

knowledge, true and correct. I give my consent for a departmental person to

contact my treating doctor, optometrist or ophthalmologist (if required), for

further information or clarification relevant to my medical condition or about

my ability to drive safely the class of vehicle authorised to be driven under the

licence applied for or currently held.

Driver s signature  (sign in the presence of

the treating doctor)

Date

/ /

*Note 1: Please complete page 1 of the Private and Commercial Vehicle Driver s Health

Assessment form F3195 before the assessment. You should be assessed using the

commercial standards under the AFTD.

a public passenger vehicle (for example, bus, taxi, limousine)?

No Yes see note 1*

a vehicle transporting dangerous goods in a receptacle with

a capacity of more than 500L or 500kgs?

No Yes see note 1*

Parts 1 and 2 of this form must be completed in full or

it will not be accepted by the department.

6. Have you been given a show cause notice, issued by a

driver licensing authority or a police officer to amend,

suspend or cancel your driver licence?

No Yes

Learner P, P1, P2 type Open

Privacy Statement: The Department of Transport and Main Roads (the

department) provides this form under the Transport Operations (Passenger

Transport) Act 1994, Transport Operations (Road Use Management) Act

1995 and the Tow Truck Act 1973 so that you may confirm your medical

fitness to drive a motor vehicle safely. The information collected on this

form is accessible by authorised departmental persons and some of this

information may be disclosed to the Queensland Police Service and

interstate driver licensing authorities. The department will not disclose

your personal information to any other third parties without your consent

unless authorised by law.