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Catalogue No. 45071506 Form No. 1546
(04/2021)
UNCLASSIFIED
SENSITIVE: HEALTH INFORMATION
6. Since last obtaining your licence, have you been prohibited
or refused from driving a motor vehicle/vessel or riding a
motorcycle in NSW or elsewhere?
No Yes
Give details
7. Since last obtaining your licence, have you been disqualified,
cancelled, suspended or is there a charge pending against
you or is your licence subject to an appeal for driving, riding
or maritime boating offences?
No
Yes
Give details
Please Note: If you answer Yes to any question from 8 - 12 for the first time, your licence may not proceed until a satisfactory NSW Fitness
to Drive medical Assessment form has been received. Visit a Service NSW Centre or call us on 13 22 13 to obtain a medical assessment
form. If you provided a medical assessment a further assessment may not be required.
8. Do you have Diabetes?
No Yes
controlled by:
Insulin
Oral medication
Diet (medical not required)
9. Do you have Epilepsy?
No Yes
10. Have you had attacks of giddiness, blackouts, fainting or
other sudden periods of unconsciousness in the last 5 years?
No Yes
11. Do you have any medical, physical or mental disabilities
which may affect your driving?
No
Yes
Give details
12. Do you regularly use drugs (such as stimulants or drugs
of addiction) other than prescription medication, which
may affect your driving?
No
Yes
Give details
13. Will you be wearing glasses or contact lenses when
driving or doing the eyesight test?
No
Yes contact lenses glasses
14. Do you have any eye or vision condition that may affect
your driving? e.g. monocular vision, double vision, visual
field defects, poor night vision.
Go to 16No
Go to 15
Yes
15. Does wearing prescription glassess or contact lenses
correct or control this condition?
Provide an eyesight report from an optometrist or doctor.
No
Yes
16. Declaration and Signature
• I declare that the contents of this Application are true and correct
• I acknowledge that it is an offence under the Road Transport Act 2013 to seek
to obtain or renew a driver licence by false statement or dishonest means
Signature Date
Day
/
Month
/
Year
Please read carefully before you sign. If you do not tell the truth you can be fined. Any licence you hold could be cancelled.
Office Use Only BUNDLE A mailing address checked on DRIVES (if applicable)
Proof of Identity record
Stand alone or primary proof
Document number Secondary proof
Date of issue or E/D
Day
/
Month
/
Year
Eyesight test/Medical report
Pass without glasses or contacts
Pass with glasses or contacts
Eyesight/Medical report
Private
Commercial
Hazard Perception test (1st attempt)
Date
/ /
Passed Failed
(2nd attempt)
Date
/ /
Passed Failed
Driver qualification test (1st attempt)
Date
/ /
Passed Failed
(2nd attempt)
Date
/ /
Passed Failed
NSW Photo Card
NSW Photo Card issued
Combined licence GLS opt in and fee paid GLS opt out, DRIVES updated
PHOTO COMPARISON
No stored image or not requested
Matched Mismatched
Customer Service
representative signature
Staff number
Date
Day
/
Month
/
Year
Personal Information Collection Notice
Transport for NSW is committed to protecting your privacy and ensuring your personal and health information is managed according to law.
Find out why we collect your personal information, including how we use and manage it, by reading our privacy statement at
www.transport.nsw.gov.au/privacy-statement or phone 13 22 13 to request a copy.
