Fillable Printable Driver License Application - Western Australia

Driver License Application - Western Australia

Driver’s Licence

Application Form

DLA 1

Government of Western Australia

Department of Transport

Driver and Vehicle Services

FREE OR REDUCED FEE LICENCES

To be eligible for a 100% concession on your driver’s licence you must present the following:

• A Centrelink aged pensioner concession card; or

• A WA senior’s card and commonwealth senior’s health card (both cards must be presented); or

• A Veteran’s Affairs pensioner concession card (where you receive a service pension and are of pension age. Please contact the

Department of Veteran’s Affairs for more information); or

• A Veteran’s Affairs gold repatriation health card - endorsed TPI or EDA.

To be eligible for a 50% concession on your driver’s licence you must present one of the following cards:

•

Any other Centrelink pensioner concession card; or

• WA senior’s card; or

• Any Veteran’s Affairs pensioner concession card (where you receive a service pension and are of pension age. Please contact the

Department of Veteran’s Affairs for more information).

Last updated: 13/01/2015

IMPORTANT - PLEASE ENSURE YOU READ THIS INFORMATION BEFORE COMPLETING THE FORM.

1. ToobtainaWAdriver’slicenceorlearner’spermityouMUSTrstproveyouridentity.Forfurtherinformation,refertothe Department

of Transport (DoT) website www.transport.wa.gov.au/dvs.

2. Youmustbeatleast15yearsand6monthsofagetoapplyforanR-N(Moped)learner’spermit,andatleast16yearsofageto

applyforaC(Car),orR-E(RestrictedMotorcycle)classlearner’spermit.Eligibilitycriteriaexistfortheissueofotherlicenceclasses.

3. EnsureyouinformDoTofanycurrent,permanentorlongtermmentalorphysicalconditionand/ortakeanymedicationthatislikely

to impair your ability to control a motor vehicle.

4. Y ou will be required to undergo an eyesight test when submitting your driver’s licence application. Please bring visual aids if applicable.

5. DoTmayrequireyoutoundertakeamedicalassessmentwithyourhealthprofessional(M107Aform)toconrmyouaremedically

ttoholdadriver’slicence.Ifamedicalassessmentisrequiredtobecompleteditmaydelaythegrantingofyourdriver’slicence.

6. YoumayonlyholdONEcurrentAustraliandriver’slicenceatanygiventime.Thelicencewillreectallclasses,restrictions,conditions

and any other relevant information. A valid interstate driver’s licence may be recognised to obtain a WA driver’s licence without

payment and must be surrendered prior to the issue of a WA driver’s licence.

7. You will be required to have a photograph taken which will be displayed on your WA plasticised learner’s permit card. This is

a mandatory requirement in accordance with legislation and there are no exceptions to this requirement.  DoT uses biometric

technology to verify that you do not currently hold a WA licence.

8. DoTmayaskyoutoprovidevericationoftheinformationyouhavesuppliedormayconductitsowninquiriesaboutthelegitimacy

of the information you have provided.

9. DoTisnotobligedtograntyoualearner’spermitordriver’slicenceunlesstheChiefExecutiveOfcerissatisedwiththeinformation

you have provided and that you meet the eligibility requirements for that learner’s permit or driver’s licence.

10. Ensure that you provide an answer to all questions asked and add any additional details where required.

11. It is important that you complete this form truthfully and not leave out any relevant information. It is a serious offence to deliberately

provide false or misleading information and penalties may apply.

Under the Road Trafc (Authorisation to Drive) Regulations 2014 you are

required to inform the Chief Executive Ofcer of any permanent, long-

term or physical condition (which may include a dependence on drugs or

alcohol)thatislikelyto,ortreatmentforwhichislikelyto,impairyourability

to controla motor vehicle.Failure to inform the Chief Executive Ofcer

may incur a penalty of up to $500.

DO YOU SUFFER FROM

APPLICANT DETAILS

MOBILE PHONE

HOME PHONE

WORK PHONE

EMAIL ADDRESS

PERSONAL DETAILS

GENDER

MALE

FEMALE

BUILD

SLIM

MEDIUM

SOLID

HEALTH AND MEDICAL QUESTIONS

FAMILYNAME

FIRSTNAME

HEIGHT

STROKE

ATTENTIONDEFICITDISORDERORATTENTION

DEFICITHYPERACTIVITYDISORDER

YES NO

ALZHEIMER’S DISEASE/DEMENTIA

ANXIETY OR DEPRESSION

ARTHRITIS

BIPOLAR

BLACKOUTS,FAINTING

DIABETES/HYPOGLYCEMIA

DIZZINESS,VERTIGO,PROBLEMSWITH

BALANCE

VISION/EYE DISORDER

HEADINJURY,SPINALINJURY

HEART DISEASE/CONDITION

i.e. Angina, chest pain, any condion requiring heart surgery

HIGH/LOW BLOOD PRESSURE

KIDNEY DISEASE

MULTIPLE SCLEROSIS

NECK,BACKORLIMBCONDITION

PARKINSON’S DISEASE

PHYSICAL DISABILITY

Including prosthetic limb

SCHIZOPHRENIA

SEIZURES,FITS,CONVULSIONS,EPILEPSY

SLEEP DISORDERS

OTHER

Ifyes,pleasegivedetails

NATURAL HAIR COLOUR

EYE COLOUR

OTHER NAME/S

YES NO

YES

DO YOU USE ILLICIT/RECREATIONAL DRUGS?

YES NO

DO YOU USE GLASSES OR CONTACT

LENSESFORDRIVING?

YES NO

DOYOUIDENTIFYASABORIGINALOR

TORRES STRAIT ISLANDER?

YES

DO YOU HAVE ANY SIBLING(S) SHARING THE

SAME DATE

OFBIRTH(e.g.MultipleBirths)?

If yes please list their names

YES NO

HAVE YOU EVER BEEN KNOWN BY ANY OTHER NAME?

(e.g. name at birth, maiden name, previous married names, Aboriginal or

tribal name, alias, adoptive name or foster name)

If yes please detail your previous/other name

YES

DATEOFBIRTH

/ /

RESIDENTIAL ADDRESS (must be in

)

Suburb

Post Code

State

W A

POSTALADDRESS(IFDIFFERENTTORESIDENTIALADDRESS)

Suburb

Post Code

State

COUNTRYOFBIRTH

TOWN

STATE

Ifyes,pleasegivedetails

AREYOUTAKINGANYMEDICATION,

WHETHER PRESCRIBED OR OTHERWISE?

(excluding Contraceptive Pill and Hormone Replacement Therapy)

YES NO

PAGE 2

eligibility criteria may apply

IMPORTANT NOTICE

• Please note there is a penalty for wilfully providing misleading

information.

• UnlessprovidedforintheRoad Trafc (Administration) Act 2008,orby

an order issued from a Court of law in Australia your personal licensing

informationcannotbedisclosedtoanythirdpartywithoutyourexplicit

consent.

• UndertheRoad Trafc (Authorisation to Drive) Regulations 2014,DoT

isentitledtorequestinformationthatsupportsyourtnesstoholda

driver ’s licence and may refuse your application if you do not provide

it.

• DoT may seek input whether directly from the driver and/or from a

healthprofessionaltosatisfytheChiefExecutiveOfcerofyourtness

to hold a driver’s licence.

• DoTmaydiscloseyourpersonalinformationtootherdriverlicensing

authorities to assess your application or verify the information you

provide.

• AnyWAlearner’spermitorWAdriver’slicenceobtainedwherefalse

ormisleadinginformation isgiven,or whereaperson isdisqualied

or prevented from holding or obtaining a learner’s permit or driver’s

licence,willbemadenullandvoid.

• Youdeclarethattheinformationonthisformistrueandcorrect.Under

the Road Trafc (Administration) Act 2008, it is an offence for anybody

to attempt to obtain or renew a driver’s licence by providing false or

misleading information.

Please read carefully before you sign. If you do not tell the truth you

can be ned and any WA licence granted to you could be cancelled.

Please sign this section in the presence of a DoT staff member/

agent.

C - Car

R-N - Moped

MC - Multi Combination

There is a penalty for wilfully providing false or misleading information.

REQUIRED LICENCE

LICENCE CONCESSIONS

DO YOU HOLD ANY OF THE FOLLOWING?

PENSIONER CONCESSION CARD

Number:

WA SENIOR’S CARD

Number:

COMMONWEALTH SENIORS HEALTH CARD

Number:

VETERANSAFFAIRSPENSIONERCONCESSIONCARD

Number:

Bymakingthisapplicationforaconcession,youaregivingconsentfor

verication of your concession with the Department of Human Services. If the

concessiondetailsareconrmed,areducedfeemayapply.Youarealsoagreeing

to contact DoT if your concession entitlement is reduced or withdrawn.

You must present your concession/health card(s) in order to be eligible for a

concessiononyourdriver’slicence.Pleasenote,thisdoesnotapplyto

your learner’s permit. You may be required to provide more information

to support your application for a concession.

APPLICANT TO ANSWER ALL QUESTIONS

PRIVACY STATEMENT AND DECLARATION

Signature

Witness Signature

C-A - Automatic T ransmission

R - Unrestricted Motorcycle

R-E - LAMS approved motorcycle

LR - Light Rigid

MR - Medium Rigid

HR - Heavy Rigid

HC - Heavy Combination

HAVE YOU EVER BEEN DISQUALIFIED FROM

DRIVING A MOTOR VEHICLE IN WA OR IN ANY

OTHERSTATE,TERRITORYORCOUNTRY?

YES NO

Ifyes,pleasegivedetails

DO YOU HAVE ANY OUTSTANDING TRAFFIC

CONVICTIONS OR CHARGES (NOT

INFRINGEMENTS) IN AUSTRALIA OR ANY

OTHER COUNTRY?

YES

Ifyes,pleasegivedetails

If you currently hold a licence issued by an Australian State or Territory

it must be surrendered when issued with your WA licence. The issuing

Authority will be advised and the licence destroyed. If any information

needs to be veried, checks may take a number of days.

Note: you may be issued with a WA learner's permit if your overseas

licence cannot be validated.

DETAILS OF ANY LICENCE HELD

HAVE YOU EVER HELD A WA LICENCE?

YES

DOYOUHOLD,ORHAVEYOUHELD,A

DRIVER’S LICENCE ISSUED BY ANOTHER

STATE,TERRITORYORCOUNTRY?

YES NO

DOYOUHOLD,ORHAVEYOUHELD,APROOF

OFAGECARDORPHOTOCARDINWAINTHE

ABOVE NAME OR IN ANOTHER NAME?

Ifyes,pleaseprovideprevious/existingidenticationcarddetails

YES NO

ISSUINGSTATE,TERRITORYORCOUNTRY

FIRSTISSUEDATE

EXPIRY DATE

LICENCE NUMBER

CLASSOFLICENCE

/ /

DATE

/ /

HAVEYOUEVERHADANAPPLICATIONFORA

DRIVER'SLICENCEREFUSEDINWAORANY

OTHERSTATE,TERRITORYORCOUNTRY?

YES NO

Ifyes,pleasegivedetails

PAGE 3

EXISTING DEPARTMENTAL IDENTIFICATION

WITNESS

NAME

OFFICE USE ONLY

NEW APPLICA TION

VARIATION

(additionalclassormodicationofrestriction)

LEARNER’S PERMIT

LAPSED LICENCE

INTERSTATETRANSFER

PREVIOUSLY SURRENDERED

PREVIOUSLY CANCELLED

OVERSEASTRANSFER

RECOGNISED COUNTRY

NON-RECOGNISED COUNTRY

EXTRAORDINARY LICENCE

APPLICATION TYPE

INTERPRETER SERVICES

WERETHESERVICESOFANINTERPRETER

USED?

Ifyes,pleasegivedetailsofinterpreter

REGISTRATION NUMBER

NAMEOFINTERPRETER

YES NO

NAME SITE

OPERATOR DETAILS

Signature

DATE

/ /

NAME

SITE

AUDITOR DETAILS

Signature

DATE

/ /

CONCESSION CHECKLIST

CONCESSION CODE (A,Por S)

CONCESSION TYPE

(A,Hor V)

CONCESSION DETAILS ENTERED ON RECORD

PHOTOCOPYOFCARD(S)ATTACHED

TESTED WITH VISUAL AIDS

VISUAL AIDS TO BE WORN WHILST DRIVING

S CONDITION LOADED/REMOVED

Eyesight tested by

MEDICAL ISSUED

Email sent to Driver Assessment to issue Medical

BOTH EYES

YES NO

YES

MEDICAL REQUIRED

YES

MEDICAL AND EYESIGHT RESULTS

RIGHT EYE

LEFTEYE

PAGE 4

OVERSEAS LICENCE CHECKLIST

CLASSCONVERSIONVERIFIED

YES

CLASS CONVERSION

OVERSEASVERIFICATIONRECEIVED?

YES (if applicable)

Signature

CONDITIONS

LICENCE CONDITIONS

DEPARTMENTAL IDENTIFICATION

CONDUCTED SEARCH FOR IDENTITY IN

EXISTING DEPARTMENTAL RECORD/S

YES

PROVISIONAL

EXPIRY DATE

/ /

WA DRIVER’S LICENCE NUMBER

LICENCE TYPE

THEORY TEST RESULTS

CTT

MOTORCYCLE

ORAL ALCOHOL

HEAVY

VEHICLE

WA LICENCE INFORMATION

CLASSESAPPLIEDFOR

EXPERIENCED DRIVER RECOGNISED COUNTRY

POI - DOCUMENTS PROVIDED BY APPLICANT

All documents provided by the applicant must be ORIGINAL (photocopies

will not be accepted).

APPLICANT FOR INITIAL WA DRIVER'S LICENCE

OPTION 1

• 1 document from Category A

• 1 from Category B

• 2 from Category C; and

• 1 from Category D (not DL69)

OPTION 2

• 1 document from Category A

• 2 from Category C; and

• 2 from Category D

All other applicants must supply 1 document from Category A or B and 1

document from Category C or D.

I have checked that the applicant has met the proof of identity requirements

and have attached copies of all documents provided unless specied

below.Theapplicant'ssignaturehasalsobeenveried.

Signature

B C C D

C C D D

DOCUMENT TYPE SIGHTED

CONVICTION CHECK

YES