UNCLASSIFIED
SENSITIVE: PERSONAL
3 Licence and registration changes
Signature
1
Customer details (include all NEW details)
Surname
Given name(s)
Residential address or business address (licence address
must be in NSW)
Mailing address
Postcode
Vehicle garage address (where the vehicle will most often be kept)
Postcode
Postcode
Your licence or customer number
Roads and Maritime is collecting your personal information to change
your details on our records and may retain and use it for driver licensing,
motor vehicle and road transport or safety purposes.
Under road transport legislation you are required to notify us if you
change your name or address or garaging address of your vehicle.
We may disclose your personal information: to other driver licensing and
vehicle registration agencies, to assess your application or verify the
information you provide and for inquiries about motor accidents.
Additionally, where you provide personal information concerning the
registration of a vehicle we may disclose that: to confirm any compulsory
third party (bodily injury) insurance is current, to anyone proposing to
acquire an interest in your vehicle, in respect of inquiries relating to stolen or
abandoned vehicles, and to any joint registere
d operator of your vehicle.
Otherwise we will not disclose your personal information without your
consent unless authorised by law.
Your personal information will be held by us. 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.
You declare that the information on this form is true and complete.
Under the road transport legislation it is an offence for anyone to attempt
to obtain or renew a driver licence, or to register or renew the
registration of a vehicle, by false statement or other dishonest means.
Privacy Statement and Declaration
Change of RecordsRoads & Maritime Products
Changes to address, name, licence, vehicle, vessel, engine details, contact details
Office-Use
Attachments
Please provide your email address if you would like to
register for an online service account. Go to service.nsw.
gov.au/online-services for more information
4
Date
day month year
Email address
/ /
Page 1 of 2
Please provide a mobile number if you would like to receive
communications from Service NSW this way
Mobile number
(continued next page)
Catalogue No. 45070212, Form No. 1021 (09/2016)
ABN 76 236 371 088
Fleet manager name (if applicable)
Contact person name
Organisation name (if applicable)
Products held (tick and complete all applicable)
What driver licence details are to be changed?
(Permanent residency status may be verified online by Roads and
Maritime with the Department of Immigration and Border Protection. For
a full list of acceptable proof of Australian residency documents, see our
website at rms.nsw.gov.au)
Driver licence or customer
number
Boat or Mooring licence
number
Combined licence - driver/boat driving
Vehicle plate number
Vessel registration number
What vehicle registration details are to be changed?
What boat or mooring licence details are to be changed?
What vessel registration details are to be changed?
2 Personal details
Date of birth
Gender
Male Female
day month year
/ /
C
Use this form to make changes to your NSW driver licence (all classes), boat licence, combined licence, NSW photo card, vehicle or vessel
registration, and/or mooring licence.
You must provide original copies of supporting documents. (Photocopies will not be accepted)
.
Customers with road products only (ie a driver licence and vehicle registration) can attend any service centre to make changes.
Combined licence holders and customers with both road and maritime products should attend a service centre or registry that
conducts maritime business.
.
For further enquiries contact a service centre or call Service NSW on 13 77 88
.
Hearing or speech impaired? Call us on the National relay Service: TTY users phone 13 36 77 then ask for 13 77 88.
Speak and Listen users phone 1300 555 727 and ask for 13 77 88
Roads and Maritime Services no longer record organ donation details. For more information visit donatelife.gov.au.
.
No Yes
(If different from residential address
All mail will be posted to this address)
UNCLASSIFIED
SENSITIVE: PERSONAL
Effective date
Conditions / Endorsements
Add/Change/Delete
Condition code
Customer service representative's signature
DateStaff number
//
day month year
//
day month year
Engine make
Motive power
Examiner's signature
Registration plate number
Engine number
Inspection report number
Authorised Examiner's use
Note: Identification numbers must be completed below,
when an examination of the vehicle required the vehicle
details to be changed.
VIN or chassis/frame number - ensure all characters are recorded
No.cylinders or rotors
Engine capacity
Gross combination mass
Overall axle spaceGross vehicle mass
Axle code WheelbaseTare weight
Vehicle fittings
Other (specify changes)
Conditions / endorsements
Station name, address and number
Name Authorised examiner
I certify I have examined the vehicle and the changed
detail/s comply in all respects with the Rules for
Authorised Inspection Stations
Examiner's number
Date
//
day month year
5 Representative's Authority
(Changes to organisation and vehicle details only)
This section must be completed if you send someone else
to conduct business on your behalf
I declare that the person below is my authorised
representative
Signature
Date
day month year
/ /
Representative's details
Name
Address
Postcode
Date of birth
day month year
/ /
Gender
Male Female
Representative's signature
Date
day month year
/ /
NSW driver licence / customer number
Page 2 of 2
Catalogue No. 45070212, Form No. 1021 (09/2016)
ABN 76 236 371 088
Nominated Configuration Code
Document produced to prove change
Stand alone or primary proof
RMS / SNSW Office Use - BUNDLE C
Proof of Identity Record
Secondary proof (if necessary)
Document number
Secondary proof issue or E/Date
Date of issue or expiry date
GAC / RMS / SNSW location
Issue centre number
//
day month year
Mailing address checked on DRIVES (if applicable)
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