Request for a Modified Licence - Roads and …

1 UNCLASSIFIED SENSITIVE: PERSONALR equest for a Modified LicenceTo Request a Modified Licence you need to complete this application form and sign the declaration. Applicant detailsSupplies (groceries etc) : Modified licences are only available for essential journeysDate of birth Day / Month / Year I understand that my personal information is collected and held by Roads and Maritime Services 20-44 Ennis Road, Milsons Point NSW 2061. I understand that my personal information is being collected as part of my application for a Modified Licence . I understand failure to supply full details and sign this declaration can result in the application not proceeding. My 'personal information' may be disclosed for the purpose of verifying this application. I have a right to access or correct my 'personal information' in accordance with the provisions of the Privacy and Personal Information Protection Act 1998. I declare that the details in this application are true and Statement and DeclarationSignature of applicantDate Day / Month / Year Day / Month / Year addressCustomer / Licence numberGiven namesClassModification and length of journeyFrequency of journeyMedical (doctor/hospital etc)Description and length of journeyFrequency of journeyCommunity (golf/bowling clubs etc)Description and length of journeyFrequency of journeyVoluntary work (meals on wheels etc)Description and length of journeyFrequency of journeyOther (relatives etc)Description and length of journeyFrequency of journeyRoads and Maritime Use OnlyCSM/SCM/Delegate commentsCSM/SCM/Delegate recommendationDate added to DRIVESCSM/SCM/Delegate signatureTake the form with your current Licence and the required fee to a registry or service centre.

2 Please call us on 13 22 13 for further advice. National Relay Service 1300 555 727 or numberCatalogue No. 45071414 Form No. 1498 (12/2017)