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PRIMARY POI
AGENT PERSONNEL NAME
AGENT PERSONNEL SIGNATURE
SECONDARY POI
DATE
/ /
Heavy commercial eyesight standards must be met to ensure that the
applicant has adequate vision to allow them to drive safely. To meet the
minimum eyesight standard for a HR, HC and/or MC class of licence, the
applicant must obtain at least 6/9 in the better eye, and at least 6/18 in the
worst eye with or without visual aids.
All identication documents must be ORIGINAL and photocopies of the original
identication must be attached to this form (photocopies must not be accepted).
One of the documents presented must show the applicant’s signature.
The name on the applicant’s identication must be the same or evidence of
a change of name that clearly shows the link between their birth name and
current name must be shown.
Where an applicant provides a debit/credit card as secondary ID, DO NOT
photocopy. Record what type of card you have sighted in the boxes below.
I have checked that the applicant has met the proof of identity requirements
and completed the health and medical section. I have completed the eyesight
test and veried the applicant’s signature.
Has the applicant declared any mental or physical
condition(s) that may impair their ability to control a
heavy commercial vehicle?
If the applicant does not meet the eyesight requirements as outlined above,
do not proceed. Contact Business and Systems Support for assistance.
If the applicant has declared a mental or physical condition(s), DO NOT
proceed. Contact Business and Systems Support for assistance.
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
YES
YES
TESTED WITH VISUAL AIDS
VISUAL AIDS TO BE WORN WHEN DRIVING
COPY OF ORIGINAL DOCUMENT ATTACHED?
COPY OF ORIGINAL DOCUMENT ATTACHED?
HAS BUSINESS AND SYSTEMS SUPPORT
BEEN CONTACTED?
HAS BUSINESS AND SYSTEMS SUPPORT
BEEN CONTACTED?
HEALTH AND MEDICAL CONDITIONS
PROOF OF IDENTITY (POI) DOCUMENTS
EYESIGHT RESULTS
AGENT USE ONLY AGENT USE ONLY CONTINUED
EYESIGHT TEST RESULTS
LEFT EYE 6/ RIGHT EYE 6/ BOTH EYES 6/
DOT USE ONLY
I have checked that the Eyesight Results, Health and Medical, POI and
Camera acknowledgement sections are complete.
OPERATOR SIGNATURE
AUDITOR DETAILS
AUDITOR NAME
SITE
AUDITOR SIGNATURE
DATE
/ /
CHECKLIST - TICK ALL RELEVANT BOXES
Health and Medical section complete
If applicant declares a medical condition, have you contacted Business
and Systems Support?
Eyesight test completed
If applicant did not meet the eyesight requirements, have you
contacted Business and Systems Support?
Proof of identity veried
Camera acknowledgement signed
Eligibility check completed through LAPS