MR205 Driver's Licence/Learner's Permit Application

1 WHAT THIS FORM IS USED FORThe first time you apply for a SouthAustralian Driver s licence or Learner YOU WILL NEEDE vidence of your age, identity and your residence as outlined in point 2below. Refer to MR583 Evidence of Iden ity brochure for more details. You may need to provide a medical or eyesight certificate, see point 5 REFER TO BACK PAGE FOR FURTHER INFORMATION AND/OR REQUIREMENTS4. OTHER PERMITS OR LICENCESIf Yes, write the driver s licence number and where it was issued.(This driver s licence must be surrendered).a)SEY NOb) Have you previously held a driver s licence or learner s Permit in South AustraliaYESNO3.

2 CLASS REQUIREDWhat class of licence do you wish to apply for? C R-Date Other (Please specify)..2. Application (Tick required boxes)I HEREBY APPLY FORLEARNER S PERMITDRIVER S LICENCEREAD THIS INFORMATION FIRSTORIGINAL DOCUMENTS ONLY. PHOTOCOPIES ARE NOT ACCEPTABLE. ONCE SIGHTED, ORIGINAL DOCUMENTS ARE RETURNED TO THE YOUR DETAILS. Please write clearly using BLOCK LETTERSGIVEN NAMESSURNAMECLIENT No. / SA licence ADDRESSPOSTAL ADDRESS(If different from above)MDATE OF BIRTH//EDOCTSOPNWOT/BRUBUSEDOCTSOPNWOT/B RUBUSThis is either your Driver s licence number or a number issued by Customer you do not know your number, please THIS FORM IS USED FORNOYESP refer not to say*This information will be used for road safety statistical analysis only and will not be disclosed to any other you of Aboriginal and/or Torres Strait Islander origin?

3 *XFmcTHGIEHRUOLOC EYEEMAIL ADDRESSt1. You must be 16 or over to apply for a learner s Y ou must provide proof of your age, and also evidence of your identity. This information may be confirmed with the issuer or official record to Evidence of Identity brochure (MR583) for more Make sure that you give all information requested and answer all questions asked. You must personally sign the Ensure that you give details of any disability or illness, including particulars of any medication. A medical certificate may be You may be requested to supply evidence that any illness or disability does not impair your ability to safely drive a motor During the term of a learner s Permit or driver s licence , you must give in writing to the Registrar of Motor Vehicles, details of any disability or illness thatmay affect your fitness to drive a motor Any learner s Permit or driver s licence issued will not be valid if false or misleading details are given.

4 Or false evidence is Any learner s Permit or driver s licence obtained when a person is disqualified or prevented from holding or obtaining a learner s Permit or driver slicence is void and of no Interstate licence must be surrendered before the issue of a South Australian Overseas licence must be surrendered before the issue of a South Australian licence (an exemption may apply).11. If a learner s Permit , provisional licence , probationary licence or driver s licence is cancelled, either as a result of a disqualification imposed under theMotor Vehicles Act or any other Act, the unexpired portion of the Permit / licence is forfeited.

5 The Motor Vehicles Regulations specifically preclude theissue of a refund on the unexpired portion, where a Permit / licence has been cancelled, and is essentially part of the penalty to encourage safe No personal information will be disclosed except as is required or authorised by complete OFFICIAL: Sensitive//Medical in confidenceDo you currently hold, or have you ever been issued, a driver s licence or Permit in another State or country? MR205 02/21 DRIVER S licence /LEARNER S Permit APPLICATIONFor further information please go to: 92 366 288 135 TESTER S CERTIFICATE OFFICE USE ONLYA pplication for a learner s Permit - complete sections for a person licensed interstate - complete sections A & for a person licensed overseas - complete sections A & C.

6 ( interstate means other States and Territories of Australia) sserddA & egA ,ytitnedI fo foorP .AB. Interstate licence TransferC. Overseas licence ConversionTESTER S DECLARATION (not to be completed if applicant FAILS).STAMP OFTESTING STATIONI certify that has passed the prescribed examination in the rules of the S NAME IN FULLSIGNATUREDATE / / Photocopy of original Interstate licence attached Has the licence been surrendered and YES NO receipt MR262 completed? Photocopy of original Overseas licence attached Has the licence been surrendered and YES NO receipt MR262 completed?

7 8. DISQUALIFICATIONS6. ORGAN DONATIONARE YOU PREPARED TO BECOME AN ORGAN DONOR?If yes, an organ donor indicator will be shown on any photo learner s Permit or driver s licence issued and will be recorded on the YESNO department s database. Your details will then be provided to the Australian Organ Donor Register who may contact you for further you DISQUALIFIED from holding or obtaining a licence or a Permit or PROHIBITED or PREVENTED from driving inSOUTH AUSTRALIA or ELSEWHERE?YESNOIf yes, give details here7. MEDICAL/IMPAIRMENTSYESNODo you have, or have you ever had any medical condition or suffered from any illness that may impair your competence to drive?

8 Cardiovascular disease, diabetes, epilepsy, hearing disorder, neurological disorder, psychiatric disorder, sleep disorder, blackouts,vertigo, frequent fainting or dizziness, high blood pressure, use of or dependency on alcohol or illicit drugs. If you answer YES, please provide you take medication for any medical condition that may affect your driving? If you answer YES, please provide you have a vision or eye condition? cataracts, glaucoma, monocular vision, diplopia etc., If you answer YES, please provide you have any disabilities or impairments that may affect your driving?

9 Disabled arm, hand, leg or foot; loss of an arm,hand, leg or foot; disabled joint; muscular disorder; deafness or arthritis. If you answer YES, please provide SIGN HERE - IT IS AN OFFENCE PUNISHABLE BY IMPRISONMENT TO MAKE A FALSE OR MISLEADING STATEMENT IN THIS HEREBY DECLARE THAT I HAVE TRUTHFULLY COMPLETED THIS FORM. 5. TRANSPORT CONCESSION. (Please tick whichever is applicable). NB: A concession is not available on LEARNER S your first totally incapacitated ex-serviceperson concession, a letter of eligibility is requiredfrom the Department of Veterans Concession Number is:I h old a Commonwealth Pensioner Entitlement CardI am a Ex-service personBy claiming a pensioner concession you are giving consent for verification of your concession status withCentrelink/Department of Veterans Affairs.

10 If the concession details are confirmed, a reduced fee may apply. Ev idence of existence - photocopy attached Ev idence of use of identity - photocopy attachedOR details of Credit/Debit card belowBank ..Card type .. Expiry Date .. / .. Ev idence of res idential address - photocopy attached At least one item showed signature and date of birth NO Is a renewal being completed?? If you answer YES, please provide glasses or corrective lenses while drivingyou REQUIRED to wear at all timesI consent to my information being checked with the document issuer or official record holder via third party systems for the purpose of confirming my identity.