Transcription of Form 5 - Application for extraordinary licence
1 MAGISTRATES COURTS of western australia Application FOR extraordinary licence Road Traffic (Authorisation to Drive) Act 2008 Magistrates Court (General) Rules 2005 Court number Magistrates court at Date lodged Applicant Full name Address Telephone no Occupation Date of birth Employment (tick one box) Self employed Not employed Employed by the employer below. Employer s name and address Details of disqualification from holding or obtaining a drivers licence Date disqualified Period disqualified Reason1 Application Under the Road Traffic (Authorisation to Drive) Act 2008 I apply for an order directing the CEO to grant an extraordinary licence that allows me to drive.
2 Vehicles of class In these localities On these days at these times For these purposes Grounds for this application2 (if insufficient space attach further supporting documents) Certificate by applicant A licence suspension order made under the Fines, Penalties and Infringement Notices Enforcement Act 1994 is not in force against me. I have not been refused an extraordinary licence by a court within the six months before the date of this Application . I am not disqualified from holding or obtaining a driver s licence under the Road Traffic Act 1974 section 71D(1).
3 Signature of applicant (or law yer) Date HEARING DETAILS This Application will be heard on Date and time Date Time or as soon after as possible, at Place Notes to Form 5: 1. If disqualified by a court after being convicted of an offence, state the court and the offence and, if the offence was against the Road Traffic Act 1974 s. 63, 64, 67 or 67A, state whether the conviction was the applicant s first, second or subsequent for the offence. 2. Note the Road Traffic (Authorisation to Drive) Act 2008 s. 30. Use numbered paragraphs.
