Fillable Drivers Licence Application Form (Services Australia)

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Drivers Licence Application Form (Services Australia)

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The Drivers Licence Application Form (Services Australia) form is 2 pages long and contains:

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  • 10 check-boxes
  • 87 other fields

Country of origin: AUSTRALIA
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Services Australia, (previously DHS - Department of Human Services) is responsible for delivering services relating to health and welfare of Australian citizens. It processes payment of child support other services.

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Government of Western Australia
Department of Transport
DLA1
Driver’s Licence Application Form
A licence holder can only hold one current Australian driver’s licence. If you
currently hold a licence issued by an Australian State or Territory it must be
surrendered upon the grant of a WA driver’s licence. The issuing authority
will be advised and the licence card destroyed. If any information needs to be
veried, checks may take a number of days.
Note: You may be granted a learner's permit if your overseas licence cannot be
validated. If your licence is not in English you must bring an ocial translation
of your original driver’s licence document, along with your overseas driver’s
licence.
Turn over to complete
DETAILS OF ANY LICENCE HELD
LICENCE NUMBER
CURRENT LICENCE: ISSUING STATE, TERRITORY OR COUNTRY
//
//
//
//
LICENCE NUMBER
FIRST ISSUE DATE
//
EXPIRY DATE
//
FIRST LICENCE: ISSUING STATE, TERRITORY OR COUNTRY
FIRST ISSUE DATE
CLASS(ES) OF LICENCE
PERSONAL DETAILS (not applicable for licence variation applicants)
APPLICANT DETAILS
FIRST NAME
OTHER NAME/S
IF YES LIST THEIR NAMES
DO YOU HAVE ANY SIBLING(S) SHARING
THE SAME DATE OF BIRTH? (e.g. multiple births)
IF YES DETAIL YOUR PREVIOUS/OTHER NAME/S
HAVE YOU EVER BEEN KNOWN BY ANY OTHER NAME?
(e.g. name at birth, maiden name, previous married names, alias, adoptive
name or foster name)
DOT WILL PROVIDE YOU WITH A DOTDIRECT ACCOUNT.
IF YOU DO NOT WANT ONE, TICK HERE:
YES
YES NO
NO
NO
DO YOU IDENTIFY AS ABORIGINAL OR
TORRES STRAIT ISLANDER?
YES
NO
FAMILY NAME
TICK TYPE OF LICENCE AND CLASS YOU REQUIRE
IMPORTANT - ENSURE YOU READ THIS INFORMATION BEFORE COMPLETING THE FORM.
YES NO
If yes, is the licence subject to an Alcohol Interlock
condition/restriction?
COUNTRY OF BIRTH
Learner’s Permit
Driver’s Licence
R - Unrestricted Motorcycle
R - E (LAMS approved motorcycle)
R - N (moped)
HC - Heavy Combination
MC - Multi Combination
C - Car
LR - Light Rigid
HR - Heavy Rigid
MR - Medium Rigid
Extraordinary Licence
Licence Variation
NATURAL HAIR COLOUR EYE COLOUR
ISSUE DATE
ISSUE DATE
ISSUE DATE
CLASS
CLASS
CLASS
• It is important to complete this form truthfully and not leave out any relevant
Information.
• Ensure that you answer all questions and provide additional information
where required.
• You may be asked to provide verication of the information you provide in
this application, or the Chief Executive Ocer (CEO) may conduct enquiries
regarding the legitimacy of the information you have provided.
• It is a serious oence to deliberately provide false or misleading information
and penalties apply.
• If you need help to ll in this form, or need to speak to us in languages other
than English, please call us on 13 11 56 or visit our website at www.transport.
wa.gov.au/dvs for location information.
• This form may be presented at a Driver and Vehicle Services (DVS) centre,
regional Department of Transport oce or DVS agent.
W A
SUBURB
RESIDENTIAL ADDRESS (MUST BE IN WA)
STATE
POST CODE
//
DATE OF BIRTH
WA LICENCE NUMBER
BUILD Slim Medium Solid
GENDER
*Supporting documents required when gender
X is selected, refer to DoT website
Male Female X*
HEIGHT
cm
YES
NOHAVE YOU EVER HELD A WA LICENCE?
DO YOU HOLD, OR HAVE YOU HELD, A DRIVER’S
LICENCE ISSUED BY ANOTHER STATE,
TERRITORY OR COUNTRY?
NOYES
SUBURB
POSTAL ADDRESS (IF DIFFERENT TO RESIDENTIAL)
STATE
POST CODE
Home Phone Work Phone
Mobile Phone
Email Address
PRIVACY STATEMENT AND DECLARATION
Please read carefully before you sign. If you do not tell the truth you can be
ned and any WA licence granted to you could be cancelled.
IMPORTANT NOTICE
• Please note there are penalties for knowingly providing misleading
information.
• Your personal driver’s licence information and photograph may be used,
or disclosed to a third party, where authorised under ‘road law’ (as dened
in the Road Trac (Administration) Act 2008), or Commonwealth law or in
compliance with a Court Order issued within Australia. Your personal details
may also be disclosed to other driver licensing authorities to assess your
application or verify any information you have provided.
• The CEO may request additional information from you in order to assess
your tness to hold a driver’s licence, which may include seeking advice
from health professionals who may have completed a medical assessment
in relation to your tness to hold a driver’s licence.
• Any WA driver’s licence obtained under false or misleading information
is void under ‘road law’, and you may be liable to prosecution if caught
driving. A driver’s licence or learner’s permit granted to a person who is
disqualied or prevented from holding or obtaining such authority will be
cancelled by the CEO.
• DoT places third-party advertising inserts in licensing communications.
If you would like to opt out of receiving these inserts, please tick here
I declare that the information on this form is true and correct. I
understand that under the Road Trac (Administration) Act 2008, it is
an oence to obtain or renew a driver’s licence by providing false or
misleading information.
Sign this section in the presence of a DoT sta member/agent.
Signature
OFFICE USE ONLY - POI DOCUMENTS PROVID
to All documents provided by the applicant must be ORIGINAL (photocopies
not be accepted).
APPLICATION FOR INITIAL WA DRIVER'S LICENCE
le.
OPTION 1
• 1 document from Category A
ur
A
B C C D
• 1 from Category B
• 2 from Category C; and
• 1 from Category D (not E40)
OPTION 2
• 1 document from Category A
A
C C D D
• 2 from Category C; and
• 2 from Category D
All other applicants must supply 1 document from Category A and C or 1
ED
INTERPRETER SERVICES
WERE THE SERVICES OF AN INTERPRETER USED? YES NO
If yes, give details of interpreter and enter details on the client history screen.
NAME OF INTERPRETER
REGISTRATION NUMBER
CLIENT’S PREFERRED LANGUAGE
OFFICE USE ONLY
CONDUCTED SEARCH FOR IDENTITY IN EXISTING
YES
DEPARTMENTAL RECORD/S.
DL NUMBER DL TYPE
CLASSES
APPLIED FOR
THEORY TEST RESULTS
ORAL TEST YES NO
CTT MOTORCYCLE
HEAVY VEHICLE
PROVISIONAL
EXPIRY DATE
/ /
CONVICTION HISTORY CHECK YES NO
ALCOHOL INTERLOCK CONDITION ADDED N/A YES NO
EXEMPTION REASON DISTANCE MEDICAL
LICENCE CONDITIONS
WA LICENCE INFORMATION
TESTED WITH VISUAL AIDS YES NO
VISUAL AIDS TO BE WORN WHEN DRIVING YES NO
50 OR S CONDITION LOADED/REMOVED YES NO
MEDICAL REQUIRED YES NO
M107A ISSUED YES NO
Email sent to Driver Suitability Services to issue M107A
BOTH
EYES
6
MEDICAL AND EYESIGHT RESULTS
RIGHT EYE
6
LEFT EYE
6
HEALTH AND MEDICAL QUESTIONS
Witness signature
Witness name
DATE
//
AUDITOR DETAILS
AUDITOR NAME SITE
AUDITOR SIGNATURE
DATE
/ /
Last updated: 13.03.2019
The Road Trac (Authorisation to Drive) Regulations 2014 requires you
inform the CEO of any permanent, long-term mental or physical condition
(which may include a dependence on drugs or alcohol) that is likely to, or
treatment for which is likely to, impair your ability to control a motor vehic
Failure to inform the CEO may incur a penalty of up to $500.
Do you suer from any mental or physical condition(s) that may impair yo
YES - Please list below
NO
NO YES - Please list below N/A
ability to control a motor vehicle?
Do you take any medication or treatment for the management of the
condition(s)?
will
document from Category B.
I have checked that the applicant has met the proof of identity requirements
and have attached copies of all documents provided.
The applicant's
signature was veried.
Operator signature
A
BC
OR
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Drivers Licence Application Form (Services Australia)

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Completed 26 July 2020

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