NSW Photo Card Application - Roads and Maritime Services

1 NSW Photo card ApplicationIMPORTANT CUSTOMER INFORMATIONTo get a NSW Photo card you must provide Proof of Identity (POI) documents. A list of acceptable documents is also available on the Roads and Maritime Services website at or in the brochure 'How to prove who you are' available at service centres and registries. If your POI documents have no signature or you cannot leave you mark/signature on this form, the 'Witness' section at item 3 must be No. 45071151 Form No. 1359 (04/2017)Page 1 of 2 Eligible NSW driver licence holders may apply for a NSW Photo card . If you apply for a NSW Photo card in the same transaction when you are renewing you licence, the NSW Photo card will be issued at a lower fee.

2 At any other time, the fee will be slightly higher. These reduced fees only apply to NSW driver licence holders. For further information, visit must be at least 16 years old and live in NSW. Eligible customers aged 21 and over may be issued with a 10 year NSW Photo USEC ustomer numberATTACHMENTSAA pplication Type:a 5 yror a 10 yrNew applicationReplacementStolenLostPoor card qualityReason:Not receivedDamaged/DestroyedPersonal details have changedChange of appearanceAPPLICANT DETAILS - PLEASE USE BLOCK LETTERSF amily nameGiven name(s)Residential addressPostcodeMailing address (if different from residential address)PostcodeNSW Licence/Customer number (if applicable)Can you produce your NSW driver licence or NSW Photo card ?

3 YesNoYou must provide your proof of identity documentsDate of birthDayMonth/Year/Gender:malefemaleMobi leEmailDo you hold or have you ever held a licence to drive or ride in NSW or a NSW PC in the name shown above or another name? NoGo to 2 YesGive details below - (Details are not required if it is the same licence/customer number as above)NSW Licence/Customer/PC numberExpiry DateDayMonth/Year/Other name (if applicable)Do you have a current: NSW Seniors card Centrelink Confirmation of Concession card Entitlement form stamped PCC DVA letter or statement certifying a disability pension of 70 percent Centrelink letter confirming Carer Allowance NSW Pensioner Concession card (PCC) Department of Veteran's Affairs (DVA) Gold card endorsed 'TPI' or 'EDA' or 'War Widow' or 'War Widower' A current intermediate pension or an assessment at 50 or more impairment pointsNoGo to 3 YesRead and complete details belowRoads and Maritime requests your consent to assess your eligibility for a concession.

4 This consent will be used for the sole purpose of authorising the Department of Human Services - Centrelink or Family and Community Services (FACS) to provide information to us to assess your eligibility in relation to concessions or Services provided by , (customer name) authorise the Department of Human Services - Centrelinkor FACS to confirm with Roads and Maritime the current status of my Commonwealth Benefit or NSW Seniors card and other details as they pertain to my concessional entitlement. This involves electronically matching details I have provided to Roads and Maritime with the Department of Human Services - Centrelink, or Department of Veterans' Affairs (DVA) records to confirm whether or not I am currently receiving a Department of Human Services - Centrelink or DVA benefit.

5 I understand that this consent, once signed, is effective only for the period I am a customer of Roads and Maritime . I also understand that this consent, which is ongoing, can be revoked any time by giving notice to Roads and Maritime . I understand that if I withdraw my consent, I may not be eligible for the concessions provided by Roads and Maritime . A brochure is available from the Department of Human Services - Centrelink that provides more details about the Centrelink Confirmation eServices or on the department's website at SignatureDayMonth/ SENSITIVE: PERSONALO ffice Use Only BUNDLE A Mailing address checked on DRIVES (if applicable)Page 2 of 2 Catalogue No.

6 45071151 Form No. 1359 (04/2017)Witness to applicant's signature (Required when you cannot): 3. Provide acceptable proof of identity document with your signature, or Leave your mark on this Application or Sign this witnessed by a parent, guardian or carer, they must attend the registry or service centre with you and show proof of their own of applicant (Please print)Signature/mark of applicantWitness declaration I certify that the applicant whose name and signature/mark appear above has signed/marked in my certify that the applicant whose name appears above is unable to sign or mark this Application for the following reasonReason why applicant can't sign this form:I understand that my personal information is being collected for verification of the applicant's signature, mark or reason for not signing the Application .

7 I am acting as a witness voluntarily. Roads and Maritime may disclose my personal information inside and outside NSW to verify the contents of this Full Name (Please print)Witness daytime phone numberWitness Driver Licence NumberWitness Address (Home or Work)Privacy Statement and Declaration Please read carefully before you sign. If you do not tell the truth you can be fined. Roads and Maritime is collecting your personal information for your NSW Photo card Application and may retain and use it for driver licensing, motor vehicle and road transport or safety purposes.

8 We are entitled to obtain your personal information under the Photo card Act 2005 and may refuse your Application if you do not provide it. We may disclose your personal information to assess your Application or verify the information you provide. Otherwise we will not disclose your personal information without your consent unless authorised by law. Your personal information including image will be held by us at 20-44 Ennis Road NSW 2061 and you can contact us to request to access or correct it. You declare that the information on this form is true and complete. Under the Photo card Act 2005 it is an offence to obtain or apply for a NSW Photo card by false statement, misrepresentation or other dishonest of applicantDayMonth/YearDate/Proof of identity record Stand alone primary proof Document numberPassport/Visa date of issue or E/DPOI for parent, guardian or carerSecondary proofPhoto comparison MismatchedMatchedNo stored image or not requestedFirst IssueReissue/replacement Photo CardNSW Driver Licence handed in or declared lost, stolen, damaged or destroyedNSW Photo card handed in or declared lost, stolen.

9 Damaged or destroyedCard DetailsVerified byCustomer Service Representative number or agency nameSignatureNameDateYear/Month/DaySigna ture of WitnessUNCLASSIFIED SENSITIVE: PERSONAL