New Customer Application (Individual)
Photo Identication Card Act 2008; Tow Truck Act 1973; Transport Operations (Marine Safety)
Act 1994; Transport Operations (Passenger Transport) Act 1994; Transport Operations (Road
Use Management) Act 1995; Transport Planning and Coordination Act 1994
TRB Forms Area F3503 V01 Apr 2019
Please use this side of the form to register yourself as a customer with
the Department of Transport and Main Roads.
3. Is your name different to the name/s on your EOI
documents?
No Yes
You are required to show an EOI change of
name document. Please provide details of your
documents.
Change of name (please print)
4. Applicant’s declaration
I declare that the information or documents given by me in this
application are complete, true and correct in every detail.
I understand that I may be prosecuted if I have stated anything in this
application that is false or misleading.
I consent to the department taking, keeping and using my personal
information, documents, digital photo and digitised signature for the
purposes of this application.
I consent to the department verifying my EOI documents or information
provided by me with the issuing authority or their agencies.
Applicant’s signature Date
/ /
It is an offence under the relevant transport Acts and the Photo
Identication Card Act to state anything or give a document to
an authorised person if you know it contains false or misleading
information. Penalties apply.
Evidence of Qld residential address (please print)
Document type
(for example telephone account)
Issue date
(for example 10/06/2015)
Document type
(for example Qld BDM
issued Marriage Certicate)
Document number
(for example 01000)
Registration year
(for example 2001)
Evidence of Identity (EOI) Requirements
You must give evidence of your identity. You may do so by showing
your Queensland (Qld) driver licence, industry authority, Marine
Licence Indicator (conditions apply), adult proof of age (APA) card
or photo identication (Photo ID) card. All cards must be current
or expired by less than two years. If you are unable to show one
of the above you will need to present three other acceptable EOI
documents, one of which must show your signature, and evidence of
your Qld residential address. If you have changed your name or the
details of your name are different on the documents provided, you
must show a change of name document from the relevant Australian
Register of Births, Deaths and Marriages (BDM). For a full list of
acceptable EOI, evidence of residential address and change of name
documents, please refer to the Evidence of Identity Requirements for
Individuals (form F4362) or visit www.qld.gov.au.
1. Applicant’s details
Family name (please print)
Given name/s
Residential address
Postcode
Postal address (if same as residential, write ‘as above’)
Postcode
2. Have you previously held a Qld driver licence,
industry authority, Marine Licence Indicator, APA
card, Photo ID card or have a customer reference
number?
Yes
No
Licence/authority/card/reference number
You are required to show three EOI documents. Please
provide details of your documents.
Daytime contact phone number Date of birth
/ /
Email address
Would you like to get e-notices and e-reminders?
Town, state and country of birth
Category A (please print)
Document type
(for example Qld BDM birth certicate)
Document number
(for example C0100011)
Category B (please print)
Document type
(for example Medicare card)
Expiry date
(if applicable)
Category A or B (please print)
Document type
Document number or expiry date
(do not give credit/debit card number)
Male (M) Female (F)Gender:
/ /
No Yes
Privacy Statement: The department collects this information under the provisions
of the Acts nominated on this form to manage the Qld driver licence, industry
authority, marine licence, APA, Photo ID, vehicle and ship registers or to issue
a product on behalf of an authorised agency. The department may disclose this
information and your digital photo to the Queensland Police Service. Information
about a driver licence may be disclosed to interstate and foreign driver licensing
authorities. Information about an APA or Photo ID card, pilot or escort vehicle
driver accreditation, driver or rider trainer accreditation, trac controller
accreditation, dangerous goods vehicle driver licence, or marine licence may
be disclosed to interstate authorities that issue the relevant card, accreditation
or licence. The department’s card production contractor will have controlled
access to your information, digitised signature and digital photo to make your
card. Information about your vehicle and ship registration may be disclosed to
interstate vehicle and ship registration authorities. Information, including your
digital photo or digitised signature, may be disclosed to an authorised agency if
the information is connected to an application for its product. Your information
will not be disclosed to any other third party without your consent, unless
required or authorised by law.
Applicant’s details conrmed in TRAILS/TICA
Applicant’s EOI conrmed
1:1 match performed
Authorising person’s declaration
I am satised the applicant’s signature matches the applicant’s EOI
documents which I have sighted.
Authorising person’s signature
Date
/ /
Authorising person’s name
Ofce Stamp
Application approved
Application not approved
Comments by authorising person
Authorising person’s checklist (tick where applicable)
