Reason for cancellation/disqualication
7. Medical Condition Reporting
Do you need to wear glasses/contact lenses for driving?
S condition will be shown on your licence
Do you have any of the following conditions? Check each statement.b.
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You must report any medical condition/s that may adversely
affect your ability to drive.
Vision or eye disorder (other than wearing glasses
or contact lenses) that may adversely affect your
Diabetes that requires treatment by tablet, insulin or
Been diagnosed with epilepsy, experienced a
seizure; or been required to take anti-epileptic
medication after the age of 11
Any other medical condition/s that is likely to
adversely affect your ability to drive safely
If you have answered Yes to any statement at 7b, you must
provide a Medical Certicate for Motor Vehicle Driver (form F3712)
completed by your treating doctor.
8. Trafc history
Have you currently, or within the last 5 years, had your licence
cancelled or been disqualied from driving or obtaining a driver
licence by an Australian or overseas court?
Provide details below
Reason for suspension
Is your licence currently suspended for any reason including
speeding offences, demerit points, unpaid nes or any other
Provide details below
9. Court Orders - restricted licence
Have you been granted a current court order for any of the
following? Check each statement.
No Yes Code
A drink or drug driving conviction X1
Special Hardship Order (SHO) X3
An order allowing you to drive until your drink or
drug driving charge is heard in court
If you have answered Yes to any of the above, you will need to
show your court order/s. The relevant code will be shown on your
licence. You must comply with the court order and carry it with you
Privacy statement: The Department of Transport and Main Roads (the
department) collects this information under the provisions of the Transport
Operations (Road Use Management) Act and Transport Planning and
Coordination Act so that you may apply for a Qld driver licence. The department
may disclose this information to interstate and foreign driver licensing authorities,
and the Queensland Police Service (QPS). Your digital photo may also be
released to the QPS. The department’s card production contractor will have
controlled access to your information, digitised signature and digital photo to
make your card. Information, including your digital photo or digitised signature,
may be disclosed to an authorised agency if the information is connected to
an application for its product. Your information will not be disclosed to any
other third party without your consent, unless required or authorised by law.
10. Applicant’s declaration
Sign only in the presence of an authorised person.
I declare that I have read the answers I have given to the
questions in this application and that the answers are complete,
true and correct in every detail.
If undertaking a practical driving test, I declare that I have the
consent of the registered operator to use the vehicle for the test.
I also declare that the registered operator has given consent for
any Driving Examiner employed by the department or any Police
Ofcer, to drive the vehicle during or in connection with the test
undertaken in the vehicle, if required.
I understand that if I have stated anything that is false or
misleading, the driver licence granted to me as a result of this
application will be absolutely void and have no legal effect
I understand that I may be prosecuted for giving or stating any
false or misleading information or documents.
I consent to the department taking, keeping and using my
personal information, documents, digital photo and digitised
signature for the purposes associated with my application.
I consent to the department verifying my EOI or evidence of
previous licence provided by me with the issuing authority or their
Additional declaration by interstate or overseas licence holders.
I understand that by signing this declaration I agree to the
surrender of my interstate driver licence.
I also consent to the department releasing information about
my application for a Qld licence to the issuing authority or their
dd mm yy
It is an offence under the Transport Operations (Road Use Management)
Act 1995 to state anything or give a document to an authorised person
if you know it contains false or misleading information. The maximum
penalty may be more than $7000.
Authorising person’s checklist
EOI sighted - address and details current on system
S or M conditions checked/added/amended
M condition reported - F3712 attached if required
Court orders/restrictions - sighted and copies attached, codes added
O/S - licence/documents sighted, copied and attached if required
O/S - translations of O/S document copied and attached if required
Application Approved / Refused
Comments by authorising person
Authorising person’s declaration
I have witnessed the applicant’s signature and checked that it
matches the applicant’s evidence of identity which I have sighted.
Authorising person’s name
Ofce stamp / date
click to sign
click to edit