Conditions
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Name
Staff number
Permit number
Corporation
If this is a telephone application make sure the applicant
understands that he/she will be bound by the conditions of the
permit and will be responsible for the suitability for safe use of the
vehicle and that any old number plates must be removed from the
vehicle before it is used and surrendered as soon as possible after
the permit has been issued.
Proof of identity record
Office use - BUNDLE B
Signature
Permit details
Secondary proof (if necessary)
Document number
Stand alone or primary proof
ACN, ARBN or other verified from: (specify document)
Customer service representative details
Conditions and details of proposed journey to be recorded
on DRIVES.
Representative Authority
Surname
Given names
9
Signature
Representative's details
Complete this to authorise another person to apply for an UVP in your
name (as long as you are recorded on the Transport for NSW
computer system).
I declare that the person named below is my authorised
representative.
State Postcode
Address
Representative's signature
NSW Driver licence/ Customer no.
Date
Date
Dealer use
Certified by dealer representative as being suitable of safe use
This vehicle is suitable for safe use and meets the
requirements of road transport legislation.
Signature
Company stamp
Declaration8
Signature
Date
day month year
/ /
day month year
/ /
day month year
/ /
You declare that:
you will be bound by the conditions as described in the permit
you will be responsible for the vehicle to be suitable for safe
use for the period of the permit
will clearly display the UVP label or notice showing the
permit number on the vehicle.
Dealer licence number
Suitable for safe use
Vehicle Suitable for Safe Use Declaration
Certification by Motor Dealer
Catalogue No. 45070190 Form No. 1019 (05/2021) ABN 18 804 239 602
Overdimension permit no. (if applicable)
Capacity if representative of a corporation
Capacity if representative
of a corporation
the information on this form is true and complete
Date of birth
day month year
/ /
Under road transport legislation, it is an offence to attempt to obtain
an UVP for a registrable vehicle, or renew the permit by false
statement or any misrepresentation or other dishonest means.
Gender male female
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.
Personal Information Collection Notice
