RMS Customer Number Application - Private customer

1 Roads and Maritime Services Customer Number Application Private Customer To get a Roads and Maritime Services (Roads and Maritime) Customer Number you must prove your Office Use identity. A copy of the brochure 'How to prove who you are' is available from a service centre or registry. You must attend in person to complete this transaction. Customer Number allocated If you cannot provide an acceptable proof of identity document that shows your signature you must complete the witness to applicant's signature section on page 2. Attachments 1 Customer details (use BLOCK LETTERS) 2 Do you hold or have you ever held a licence to drive or Name ride in NSW, or a Roads and Maritime issued photo card or conducted any business, such as registering a vehicle, with Roads and Maritime that required the issue of a Customer Number in the above name or in another name? no Residential address yes Give details below Licence/ Customer Number Class of licence State Postcode Expiry date Registration plate Number Mailing address (if different from residential address).

2 Day / month / year Other name State Postcode What other business have you conducted? Email address 3 Customer consent Roads and Maritime is collecting your personal information in order Mobile Number (please provide a mobile phone Number if you to create your Roads and Maritime Customer Number . We may would like to receive communications from Roads and retain and use your personal information for driver licensing, motor Maritime this way) vehicle, road transport and safety purposes. Providing this information is voluntary but we may refuse your Application unless you do so in which case you may not be able to transact business with us. Date of birth We may disclose your personal information to other driver licensing and vehicle registration agencies, to assess your Application or day / month / year verify the information you provide, for inquiries about motor accidents, to confirm compulsory third party (bodily injury). insurance is current, to anyone proposing to acquire an interest in Sex your vehicle and in respect of inquiries relating to stolen or male abandoned vehicles.

3 Female Otherwise we will not disclose your personal information without your consent unless authorised by law. Pensioner Number (if applicable) Your personal information will be held by Roads and Maritime at 20-44 Ennis Road, Milsons Point NSW 2061. You have the right to access and correct the information if you believe that it is incorrect. You declare that the information on this form is true and complete. Signature Date day / month / year Continued next page Catalogue No. 45071265 Form (07/2017) Page 1 of 2. UNCLASSIFIED. SENSITIVE: PERSONAL. 4 Witness to applicant's signature Office use only Required when you cannot provide an acceptable proof of Reason for establishment of Customer identity document that shows your signature. If witnessed by a parent or guardian they must attend the motor registry with you and show proof of their own identity. Name of applicant (block letters) Proof of identity record Stand-alone or primary proof Signature of applicant Passport / Visa - Document Number date of issue or Expiry Date Witness declaration day / month / year I certify that the applicant, whose name and signature Secondary proof appears on this form has signed in the signature box in my presence.

4 My personal information is being collected for verification of the applicant's signature. My witnessing of the applicant's Date of issue or expiry date signature is voluntary. My personal information held by Roads and Maritime may be disclosed inside and outside NSW to verify the contents of this Application . day / month / year Name of witness (block letters). Parent or Guardian Proof of Identity Type of proof Signature of witness Verified by Position of witness - Employer / school principal / bank CSR's name manager / parent / guardian (cross out those not applicable). Daytime contact phone Date Number of witness CSR's signature day / month / year Business address of witness (can be residential address of parent / guardian) CSR's staff Number State Postcode UNCLASSIFIED. SENSITIVE: PERSONAL. Catalogue No. 45071265 Form (07/2017) Page 2 of 2. Cut here and hand to Customer Office Use Only Customer name Customer Number