Conditions
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Name
Staff number
Permit number
Corporation
If this is a telephone application make sure the applicant
understands that he/she will be bound by the conditions of the
permit and will be responsible for the suitability for safe use of the
vehicle and that any old number plates must be removed from the
vehicle before it is used and surrendered as soon as possible after
the permit has been issued.
Proof of identity record
Office use - BUNDLE B
Signature
Permit details
Secondary proof (if necessary)
Document number
Stand alone or primary proof
ACN, ARBN or other verified from: (specify document)
Customer service representative details
Conditions and details of proposed journey to be recorded
on DRIVES.
Representative Authority
Surname
Given names
9
Signature
Representative's details
Complete this to authorise another person to apply for an UVP in your
name (as long as you are recorded on the Roads and Maritime
computer system).
I declare that the person named below is my authorised
representative.
State Postcode
Address
Representative's signature
NSW Driver licence/ Customer no.
Date
Date
Dealer use
Certified by dealer representative as being suitable of safe use
This vehicle is suitable for safe use and meets the
requirements of road transport legislation.
Signature
Company stamp
Privacy Statement and Declaration
Roads and Maritime Services is collecting your personal information
in relation to your application for an UVP and may retain and use it
for driver licensing, motor vehicle, road transport and safety
purposes. You are required to provide this information under road
transport legislation and we may refuse your application if you do
not provide it.
We may disclose your personal information to other driver licensing
and vehicle registration agencies, to assess your application or
verify the information you provide, for inquiries about motor
accidents, to confirm compulsory third party (bodily injury)
insurance is current, to anyone proposing to acquire an interest in
your vehicle and in respect of inquiries relating to stolen or
abandoned vehicles. Otherwise we will not disclose your personal
information without your consent unless authorised by law. We are
subject to the Privacy and Personal Information Protection Act and
the Health Records and Information Privacy Act.
Your personal information will be held by us at 20-44 Ennis Rd,
Milsons Point NSW 2061. You have the right to access and correct
the information if you believe that it is incorrect. You can contact us
to request to access or correct it
8
Signature
Date
day month year
/ /
day month year
/ /
day month year
/ /
You declare that:
you will be bound by the conditions as described in the permit
you will be responsible for the vehicle to be suitable for safe
use for the period of the permit
will clearly display the UVP label or notice showing the
permit number on the vehicle.
Dealer licence number
Suitable for safe use
Vehicle Suitable for Safe Use Declaration
Certification by Motor Dealer
Catalogue No. 45070190 Form No. 1019 (12/2016) ABN 76 236 371 088
Overdimension permit no. (if applicable)
Capacity if representative of a corporation
Capacity if representative
of a corporation
the information on this form is true and complete
Date of birth
day month year
/ /
Under road transport legislation, it is an offence to attempt to obtain
an UVP for a registrable vehicle, or renew the permit by false
statement or any misrepresentation or other dishonest means.
Gender male female
UNCLASSIFIED
SENSITIVE: PERSONAL
