Page 3 of 3 TRB Forms Area Form F1854 CFD V01 Apr 2016
Vehicle Modication Application continued... Page 3 of 3
Provide details of donor vehicle
Year of manufacture Number of cylinders/rotors
Fuel type: Petrol Diesel LPG
Privacy Statement: The Department of Transport and Main Roads collects the information on this form under the Transport Operations (Road Use Management) Act to
assess your application for approval of a modication. This information may be released by the department or its agents/contractors to parties such as vehicle insurers,
statutory/insolvency entities, lawyers, persons involved in vehicle accidents/incidents and to or through interstate registering authorities. The information is accessible
by authorised departmental ofcers and your personal information will not be disclosed to other third parties without your consent unless authorised or required by law.
I hereby declare the information provided on this form, and any supporting information provided, to be true and correct.
Signature of applicant
Business name (if applicable)
This completed form can be emailed to firstname.lastname@example.org or sent to:
Department of Transport and Main Roads
PO Box 673
Fortitude Valley, Qld 4006
For further information visit the Department of Transport and Main Roads website at www.tmr.qld.gov.au.
Ofce Use Only
Date received File reference number