Fillable Heavy Vehicle PDA Customer Eligibility (Services Australia)

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Heavy Vehicle PDA Customer Eligibility (Services Australia)

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The Heavy Vehicle PDA Customer Eligibility (Services Australia) form is 2 pages long and contains:

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  • 9 check-boxes
  • 53 other fields

Country of origin: AUSTRALIA
File type: PDF

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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
E114
Heavy Vehicle PDA Customer Eligibility
LICENCE CLASS REQUIRED
APPLICANT DETAILS (to be completed by applicant)
AUTHORISED PROVIDER DETAILS
FAMILY NAME
PHONE NUMBER
TRADING AS
COMPANY NAME
WA DRIVER’S LICENCE NUMBER
AUTHORISED PROVIDER NUMBER
FIRST NAME
MOBILE NUMBER
OTHER NAME/S
EMAIL ADDRESS
HEALTH AND MEDICAL QUESTIONS
DATE OF BIRTH
/ /
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 provide
false or misleading information.
Sign this section in the presence of a DoT agent.
APPLICANT SIGNATURE
I acknowledge that by choosing to do my heavy Practical Driving Assessment
(PDA) through an authorised provider (agent of DoT) I will be video/audio
and GPS recorded during the assessment. The recording taken during my
assessment may be viewed in actual time/live or later by DoT authorised
ocers.
For further information on the use of recording equipment, contact DoT or
visit www.transport.wa.gov.au
Sign this section in the presence of a DoT agent.
APPLICANT SIGNATURE
AGENT PERSONNEL FULL NAME
AGENT PERSONNEL FULL NAME
AGENT PERSONNEL SIGNATURE
AGENT PERSONNEL SIGNATURE
DATE
DATE
/ /
/ /
DECLARATION
CAMERA ACKNOWLEDGEMENT
The Road Trac (Authorisation to Drive) Regulations 2014 requires you to
declare 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 heavy commercial vehicle.
Last updated: 14.12.2021
HR - Heavy Rigid
HC - Heavy Combination
MC - Multi Combination
W A
SUBURB
RESIDENTIAL ADDRESS
STATE
POST CODE
W A
SUBURB
BUSINESS ADDRESS
STATE
POST CODE
Requirements:
• Complete the health and medical section.
• Conduct the eyesight test per the Department’s requirements.
• Verify acceptable forms of identication (Proof of Identity).
• Sign the camera acknowledgement section.
• Complete eligibility check through the Licence Assessment Provider System (LAPS).
Note: You MUST take this form to the Department of Transport (DoT) to have the class added to your driver’s licence record.
This is not a licence to drive the class described.
When blank, this form is classed as OFFICIAL, when completed, this form is classed as OFFICIAL SENSITIVE
YES NO
Do you suer from any mental or physical condition(s) that may impair your
ability to control a heavy commercial vehicle?
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 identication documents must be ORIGINAL and photocopies of the original
identication 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 identication 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 veried 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 veried
Camera acknowledgement signed
Eligibility check completed through LAPS
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Heavy Vehicle PDA Customer Eligibility (Services Australia)

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Completed 11 April 2022

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