Fillable Printable Learning Driving Licence Form - South Australia
Fillable Printable Learning Driving Licence Form - South Australia
Learning Driving Licence Form - South Australia
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 Idenity brochure for more details.
• You may need to provide a medical or eyesight certificate, see point 5 below.
PLEASE REFER TO BACK PAGE FOR FURTHER INFORMATION AND/OR REQUIREMENTS
4. OTHER PERMITS OR LICENCES
If Yes, write the driver’s licence number and where it was issued.
(This driver’s licence must be surrendered).
a) Are you, or have you been authorised to drive in another
SEY ?yrtnuoc ro etatS
NO
b) Have you previously held a driver’s licence or learner’s permit in South Australia YES NO
3. CLASS REQUIRED
What class of Licence do you wish to apply for?
“C” “R-Date” “Other” (Please specify)............................................................................................................
2. APPLICATION (Tick required boxes)
I HEREBY APPLY FOR LEARNER’S PERMIT DRIVER’S LICENCE
READ THIS INFORMATION FIRST
1. You must be 16 or over to apply for a learner’s permit.
2. You must provide proof of your age, and also evidence of your identity. Refer to Evidence of Identity brochure (MR583) for more information.
3. Make sure that you give all information requested and answer all questions asked. You must personally sign the application.
4. Ensure that you give details of any disability or illness, including particulars of any medication. A medical certificate may be required.
5. You may be requested to supply evidence that any illness or disability does not impair your ability to safely drive a motor vehicle.*
6. During 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. Any 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. Any 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. Overseas 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. No 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
GIVEN NAMES
SURNAME
CLIENT No. / SA Licence No.
HOME ADDRESS
TOWN/STATE
COUNTRY OF BIRTH
POSTAL ADDRESS
(If different from above)
Male
Female
DATE OF BIRTH / /
mcTHGIEHRUOLOC EYE
EDOCTSOPNWOT/BRUBUS
EDOCTSOPNWOT/BRUBUS
This is either your Driver’s Licence number or a number issued by Customer Services.
If you do not know your number, please enquire.
PHONE
GENDER
MR205 06/13
DRIVER’S LICENCE/LEARNER’S
PERMIT APPLICATION
WHAT THIS FORM IS USED FOR
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.
Are you of Aboriginal and/or Torres Strait Islander origin?*
Lodge at any Service SA Centre
For service SA locations www.sa.gov.au/customerservice or call 13 10 84 between 8am - 6pm Monday to Friday
Post to: Service SA, Customer Service Section, GPO Box 1533, Adelaide SA 5001
www.sa.gov.au/driverslicences ABN 92 366 288 135
EXAMINER’S CERTIFICATE
OFFICE USE ONLY
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)
sserddA & egA ,ytitnedI fo foorP .A
B. Interstate Licence Transfer
C. Overseas Licence Conversion
EXAMINER’S DECLARATION (not to be completed if applicant FAILS).
STAMP OF
TESTING STATION
I certify that
has passed the prescribed examination in the rules of the road.
SIGNATURE
DATE / /
• Photocopy of original Interstate Licence attached
• Has the licence been surrendered and YES NO
receipt MR262 completed?
• Photocopy of original Overseas Licence attached
• Has the licence been surrendered and YES NO
receipt MR262 completed?
8. DISQUALIFICATIONS
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.
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
7. MEDICAL/IMPAIRMENTS
YES NO
Do you have, or have you ever had any medical condition or suffered from any illness that may impair your competence to drive?
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.
Do you have an eyesight deficiency or wear glasses or contact lenses for 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
YES NO
9. SIGN HERE - IT IS AN OFFENCE PUNISHABLE BY IMPRISONMENT TO MAKE A FALSE OR MISLEADING STATEMENT IN THIS APPLICATION.
SIGNATURE DATE / /
I HEREBY DECLARE THAT I HAVE TRUTHFULLY COMPLETED THIS FORM. No personal information will be disclosed except as is
required or authorised by law.
5. TRANSPORT CONCESSION. (Please tick whichever is applicable). NB: A concession is not available on LEARNER’S PERMITS.
For your first totally incapacitated Ex-service
person concession, a letter of eligibility is required
from the Department of Veterans’ Affairs
My Concession Number is:
I hold a State Concession Card
I hold a Commonwealth Pensioner Entitlement Card
I am a T.P.I. Ex-service person
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.
• Evidence of existence - photocopy attached
• Evidence of use of identity - photocopy attached
OR details of Credit/Debit card below
Bank ................................................................................................................
Card type ............................................. Expiry Date ................. / ...............
• Evidence of residential address - photocopy attached
• At least one item showed signature and date of birth
