Fillable NSW Photo Card Application A (New South Wales)

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NSW Photo Card Application A (New South Wales)

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The NSW Photo Card Application A (New South Wales) form is 2 pages long and contains:

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  • 29 check-boxes
  • 25 other fields

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File type: PDF

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NSW Photo Card Application
IMPORTANT CUSTOMER INFORMATION
To get a NSW Photo Card you must provide Proof of Identity (POI) documents. A list of acceptable documents is also available on the
Roads and Maritime Services website at rms.nsw.gov.au or in the brochure 'How to prove who you are' available at service centres
and registries.
If your POI documents have no signature or you cannot leave you mark/signature on this form, the 'Witness' section at item 3 must be
completed.
Catalogue No. 45071151 Form No. 1359 (04/2017) Page 1 of 2
Eligible NSW driver licence holders may apply for a NSW Photo Card. If you apply for a NSW Photo Card in the same transaction
when you are renewing you licence, the NSW Photo Card will be issued at a lower fee. At any other time, the fee will be slightly
higher. These reduced fees only apply to NSW driver licence holders. For further information, visit rms.nsw.gov.au.
You must be at least 16 years old and live in NSW. Eligible customers aged 21 and over may be issued with a 10 year NSW Photo Card.
OFFICE USE
Customer number
ATTACHMENTS
A
Application Type:
a 5 yr or a 10 yr
New application
Replacement
Stolen Lost Poor card qualityReason: Not receivedDamaged/Destroyed
Personal details have changed
Change of appearance
APPLICANT DETAILS - PLEASE USE BLOCK LETTERS
Family name
Given name(s)
Residential address
Postcode
Mailing address (if different from residential address)
Postcode
NSW Licence/Customer number (if applicable) Can you produce your NSW driver licence or NSW Photo card?
Yes
No
You must provide your proof of identity documents
Date of birth
Day Month
/
Year
/
Gender: male female
Mobile Email
Do you hold or have you ever held a licence to drive or ride in NSW or a NSW PC in the name shown above or another name?
No
Go to 2
Yes
Give details below - (Details are not required if it is the same licence/customer number as above)
NSW Licence/Customer/PC number
Expiry Date
Day Month
/
Year
/
Other name (if applicable)
Do you have a current:
• NSW Seniors Card
• Centrelink Confirmation of Concession Card
Entitlement form stamped PCC
• DVA letter or statement certifying a disability pension of
70 percent
• Centrelink letter confirming Carer Allowance
• NSW Pensioner Concession Card (PCC)
• Department of Veteran's Affairs (DVA) Gold Card endorsed
'TPI' or 'EDA' or 'War Widow' or 'War Widower'
• A current intermediate pension or an assessment at 50 or
more impairment points
No
Go to 3
Yes
Read and complete details below
Roads and Maritime requests your consent to assess your eligibility for a concession. This consent will be used for the sole purpose
of authorising the Department of Human Services - Centrelink or Family and Community Services (FACS) to provide information to
us to assess your eligibility in relation to concessions or services provided by us.
I, (customer name)
authorise the Department of Human Services - Centrelink
or FACS to confirm with Roads and Maritime the current status of my Commonwealth Benefit or NSW Seniors Card and other
details as they pertain to my concessional entitlement. This involves electronically matching details I have provided to Roads and
Maritime with the Department of Human Services - Centrelink, or Department of Veterans' Affairs (DVA) records to confirm whether
or not I am currently receiving a Department of Human Services - Centrelink or DVA benefit.
I understand that this consent, once signed, is effective only for the period I am a customer of Roads and Maritime. I also
understand that this consent, which is ongoing, can be revoked any time by giving notice to Roads and Maritime.
I understand that if I withdraw my consent, I may not be eligible for the concessions provided by Roads and Maritime.
A brochure is available from the Department of Human Services - Centrelink that provides more details about the Centrelink
Confirmation eServices or on the department's website at humanservices.gov.au.
Signature
Day Month
/
Year
Date
/
1.
2.
UNCLASSIFIED
SENSITIVE: PERSONAL
Office Use Only BUNDLE A Mailing address checked on DRIVES (if applicable)
Page 2 of 2Catalogue No. 45071151 Form No. 1359 (04/2017)
Witness to applicant's signature (Required when you cannot):
3.
• Provide acceptable proof of identity document with your signature, or
• Leave your mark on this application or
• Sign this application.
If witnessed by a parent, guardian or carer, they must attend the registry or service centre with you and show proof of their own identity.
Name of applicant (Please print)
Signature/mark of applicant
Witness declaration
I certify that the applicant whose name and signature/mark appear above has signed/marked in my presence.
I certify that the applicant whose name appears above is unable to sign or mark this application for the following reason
Reason why applicant can't sign this form:
I understand that my personal information is being collected for verification of the applicant's signature, mark or reason for not
signing the application. I am acting as a witness voluntarily. Roads and Maritime may disclose my personal information inside and
outside NSW to verify the contents of this application.
Witness Full Name (Please print)
Witness daytime phone numberWitness Driver Licence Number
Witness Address (Home or Work)
Privacy Statement and Declaration Please read carefully before you sign. If you do not tell the truth you can be fined.
Roads and Maritime is collecting your personal information for your NSW Photo Card application and may retain and use it for
driver licensing, motor vehicle and road transport or safety purposes. We are entitled to obtain your personal information under the
Photo Card Act 2005 and may refuse your application if you do not provide it. We may disclose your personal information to assess
your application or verify the information you provide. Otherwise we will not disclose your personal information without your consent
unless authorised by law. Your personal information including image will be held by us at 20-44 Ennis Road NSW 2061 and you
can contact us to request to access or correct it.
You declare that the information on this form is true and complete. Under the Photo Card Act 2005 it is an offence to obtain or apply
for a NSW Photo Card by false statement, misrepresentation or other dishonest means.
4.
Signature of applicant
Day Month
/
Year
Date
/
Proof of identity record Stand alone primary proof Document number Passport/Visa date of issue or E/D
POI for parent, guardian or carerSecondary proof
Photo comparison
MismatchedMatched
No stored image or not requested
First Issue
Reissue/replacement
Photo Card
NSW Driver Licence handed in or
declared lost, stolen, damaged or
destroyed
NSW Photo Card handed in or
declared lost, stolen, damaged
or destroyed
Card Details
Verified by
Customer Service Representative
number or agency name
SignatureName Date
Year
/
Month
/
Day
Signature of Witness
UNCLASSIFIED
SENSITIVE: PERSONAL
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NSW Photo Card Application A (New South Wales)

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Completed 12 August 2020

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