MR206 07/16
P1 OR P2 PROVISIONAL LICENCE/DRIVER’S LICENCE/LEARNER’S
PERMIT RENEWAL, REPLACEMENT AND ISSUE APPLICATION
WHAT YOU WILL NEED
RENEWAL
ISSUE or REPLACEMENT must provide Full Evidence of Identity
• Provide your South Australian Driver’s Licence or
• For first ever issue of a licence or
• You need to provide full evidence of identity, unless your portrait and
signature are already digitally stored (please enquire).
• If unable to provide their licence (if portrait & signature not digitally stored)
• Refer to MR583 Evidence of Identity brochure for more details.
• Refer to MR583 Evidence of Identity brochure for more details.
1. YOUR DETAILS. Please write clearly using BLOCK LETTERS.
No personal information will be disclosed except as is required or authorised by law.
This is either your Driver’s Licence number or a number issued by Customer Services. If you don’t know your
number, please enquire.
CLIENT No.
GENDER
SURNAME
GIVEN NAMES
DATE OF BIRTH
EMAIL ADDRESS
F
M
X
/
EYE COLOUR
/
HEIGHT
cm
HOME ADDRESS
SUBURB/TOWN
POSTCODE
PHONE
POSTAL ADDRESS
(If different from above)
SUBURB/TOWN
POSTCODE
Are you of Aboriginal and/or Torres Strait Islander origin?*
NO
YES
Prefer not to say
*This information will be used for road safety statistical analysis only and will not be disclosed to any other authorities.
2. APPLICATION FOR (Tick required boxes)
Provisional licence
Learner’s permit
Renewal, number of years (1 - 10 years).............
First issue, class....... (C, R-Date, HC)
First issue P1 licence
Renewal (class C only)
Renewal of P1 or P2 licence
Replacement
*Complete declaration below
Reapplying for permit following a disqualification
Upgrade from P1 to P2 licence
Reapply after appeal
Temporary driving permit
Replacement
*Complete declaration below
Full licence
Replacement
*Complete declaration below
Re-applying after disqualification / appeal
Remove a licence condition
First issue, number of years (1 - 10 years).............
Upgrade from P2 to full licence,
number of years (1 - 10 years).............
Upgrade from P1 to full licence,
number of years (1 - 10 years).............
Add class ............ to my licence
Replacement *Complete declaration below
Probationary licence after a disqualification
Remove a licence condition
*Please give reason for replacement here. I declare that the licence/permit
issued to me has been - (surrendered, lost, destroyed etc.)........................................................................................................................................................................
OFFICE USE ONLY
EVIDENCE OF IDENTITY DOCUMENTS SIGHTED
CLIENT No.
EVIDENCE OF EXISTENCE
SIGNATURE OF VERIFYING OFFICER
EVIDENCE OF USE OF IDENTITY
USER ID
EVIDENCE OF RESIDENTIAL ADDRESS
DATE
/
PLEASE REFER TO THE BACK PAGE FOR FURTHER INFORMATION AND/OR REQUIREMENTS
Lodge at any Service SA Centre
For Service SA locations www.sa.gov.au/customerservice
Telephone Enquiries: 13 10 84 Post to: Service SA, Customer Service Section, GPO Box 1533, Adelaide SA 5001
www.sa.gov.au/driverslicences ABN 92 366 288 135
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3. TRANSPORT CONCESSION. (Please tick whichever is applicable). NB: A concession is not available on LEARNER’S PERMITS.
I hold a State Concession Card
I hold a Commonwealth Pensioner Entitlement Card
I am a TPI Ex-service person
My Concession Number is:
For incapacitated Ex-service person concessions,
a letter of eligibility may be required from the
Department of Veterans’ Affairs
By claiming a pensioner concession, you are giving consent for verification of your concession status with Centrelink/Department of Veterans’
Affairs. If the concession details are confirmed, a reduced fee may apply.
4. MEDICAL CONDITIONS / IMPAIRMENTS
You must ensure that you give details of any disability or illness, including particulars of any medication. A medical certificate may be required.
During the term of a learner's permit, P1 or P2 provisional licence, probationary or driver's licence, you must give in writing to the Registrar of Motor Vehicles,
details of any disability or illness that may affect your fitness to drive a motor vehicle.
Do you have, or have you ever had any medical condition or suffered from any illness that may impair your competence to drive?
E.g. 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 details.
YES
NO
Do you take medication for any medical condition that may affect your driving?
If you answer YES, please provide details.
YES
NO
Do you have an eyesight deficiency or wear glasses or contact lenses for driving?
If you answer YES, please provide details.
YES
NO
Do you have any disabilities or impairment that may affect your driving?
E.g. disabled arm, hand, leg or foot; loss of an arm, hand, leg or foot; disabled joint; muscular disorder; or arthritis.
If you answer YES, please provide details.
YES
NO
5. DISQUALIFICATIONS
Are you DISQUALIFIED from holding or obtaining a licence or a permit or PROHIBITED or PREVENTED from driving in SOUTH AUSTRALIA or ELSEWHERE?
YES
NO
YES
NO
If yes, give details here
6. OTHER LICENCES
Are you, or have you been authorised to drive in another State or country?
If YES, please provide detail
i.e. Type, Class, Place of Issue
7. ORGAN DONATION – OPTIONAL QUESTION
ARE YOU PREPARED TO BECOME AN ORGAN DONOR?
If yes, an organ donor indicator will be shown on any photo learner’s permit, P1 or P2 provisional licence or driver’s licence issued and YES
NO
recorded on the department’s database. Your details will be provided to the “Australian Organ Donor Register” who may
C Ccontact you for further details.
8. SIGN HERE - IT IS AN OFFENCE PUNISHABLE BY IMPRISONMENT TO MAKE A FALSE OR MISLEADING STATEMENT.
• Any learner’s permit, P1 or P2 provisional licence or driver's licence issued will not be valid if false or misleading details are given, or false evidence supplied.
• Any learner's permit or P1 or P2 provisional licence or driver's licence obtained when a person is disqualified or prevented from holding or obtaining a learner's
permit or P1 or P2 provisional licence or driver’s licence is void and of no effect.
• A renewal of a P1 or P2 provisional licence or driver's licence paid after the expiry date will:
• up to 6 months: expiry date not altered;
• over 6 months: additional licence administration fee.
• If a learner's permit, P1 or P2 provisional licence, probationary licence or driver’s licence is cancelled, either as a result of a disqualification imposed under the
Motor Vehicles Act or any other Act, the unexpired portion of the permit/licence is forfeited. The Motor Vehicles Regulations specifically preclude the issue of a
refund on the unexpired portion, where a licence has been cancelled, and is essentially part of the penalty to encourage safe driving.
I HEREBY DECLARE THAT I HAVE TRUTHFULLY COMPLETED THIS FORM.
SIGNATURE
DATE
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