UNCLASSIFIED
SENSITIVE: PERSONAL
NSW Driver's licence/Customer number
Given names
Surname
Address
Postcode
1
Declaration (to be completed by the club's Responsible Person)
Club membership details (nominate primary club first)
Model (in full - name, letters and/or numbers, variant)
Plate number (if known)
Engine number
VIN or chassis/frame or serial number
2 Vehicle details
Make Model year
Shape
Vehicle type
I certify that this vehicle meets the eligibility requirements of the
Historic Vehicle Scheme
The registered operator is a financial member of the club.
Name
Signature
Motorcycle TruckCar/Station Wagon
Bus PlantTrailer
Please specify
Other
3
(A Safety Check report must be provided if the club is less
than two years old)
Registered operator details
Name
The vehicle is in a safe operating condition.
Signature
Safety Inspection report number
Or
Date
day month year
Vehicle eligibility (to be completed by the club's
Responsible Person)
4
The registered operator (or applicant) is responsible for the vehicle to be suitable for safe use until the expiry date of the registration.
A Safety Check report must be provided if the club is less than two years old.
The registered operator must be a member of an Roads and Maritime Services recognised Historic Vehicle Club in the Historic
Vehicle Scheme.
Historic Vehicle Declaration
/ /
Date
day month year
/ /
Date
day month year
/ /
Catalogue No. 45070967 Form No. 1259 (01/2019)
The vehicle must be 30 years of age or older and meet eligibility requirements of the Historic Vehicle Scheme.
Primary Club Stamp
Page 1
This form must be submitted as an original. Photocopies will not be accepted.
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