Safer Driver Course - Concession Application

1 UNCLASSIFIED SENSITIVE: PERSONALS afer drivers Course Concession ApplicationYou must provide Proof of Identity (POI) documents and any original supporting documents (photocopies are not acceptable). Safer drivers Course provider contact information can be found at detailsApplicant's signaturedaymonthyearDatePage 1 of 1 Family nameResidential address (licence address must be in NSW)Given namesLicence numberDate of birthI receive Centrelink benefits and hold a current Pensioner Concession card. I certify the information given in this Application is correct at the date of signing. I understand, should I be granted full Concession for the Safer drivers Course that my Course booking is not transferable for use by another declarationPensioner Concession validation consentSafer drivers Course provider use onlyProof of Identity RecordConcession typeConcession card numberProvider locationSignature of person who sighted Pension Concession card and learner licenceStaff licence numberDateNumber of attachmentsConcession card numberExpiry dateI authorise Roads and Maritime Services to confirm with Centrelink details about my pension entitlement.

2 This includes whether or not the details I have provided Roads and Maritime match Centrelink or Department of Veterans' Affairs (DVA) records and whether or not I am still receiving a Centrelink or DVA benefit. I agree, unless I revoke my consent, this Customer Consent record is a permanent consent, and may be relied on until such time as I revoke it. I may revoke my consent at any time by giving Roads and Maritime written notice. I understand if I revoke my consent, I will not be eligible for pensioner concessions provided by Roads and Maritime. I understand that my "personal Information" is collected, held by Roads and Maritime, 20-44 Ennis Road, Milsons Point 2061. I declare that the details in this Application are true and complete.

3 I understand that: my "personal Information" is being collected to authorise verification of my details with Centrelink/Department of Veteran Affairs for eligibility for a Concession Entitlement. Failure to supply full details and sign this authority can result in the Concession being denied. My "personal Information" will only be disclosed to verify this information. I have a right to access or correct my "personal information" in accordance with the provisions of the relevant Privacy of providerLearner licence numberLicence card numberCentrelink Customer Reference Number (CRN)Department of Veterans' Affairs (OVA) file numberMy Portal case numberCatalogue No. 45072000, Form No. 1810 (04/2019)Answering this question is voluntary. We may use this information to develop Driver licensing and vehicle registration services for Aboriginal people.

4 We will not disclose this information without your consent unless authorised by lawAre you an Aboriginal person or Torres Strait Islander?YesNoOther customers eligible for concessionAre you a current or former Out of Home Care (OOHC) client?YesNoAre you a current or former Driver Licensing Access Program (DLAP) participant?YesNo