Driver Licence Application/Renewal

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(Learner, P1, P2, P type and Open Licence)

Transport Operations (Road Use Management) Act 1995
Transport Planning and Coordination Act 1994
Are you eligible for a Queensland (Qld) Driver Licence? 3. Evidence of identity (EOI) and Qld residency
To be eligible for a driver licence in Qld you must: a. Can you show your Qld Driver Licence, Industry Authority,
Marine Licence (with photo) or Adult Proof of Age card that is
• prove your identity using original documents current or expired less than 2 years ago?
• be a resident of Qld
• disclose medical conditions that may adversely affect your ability to No ✔ Yes Licence/reference number
drive safely. Go to 4.
You are not eligible to make this application if your licence is
b. If you cannot show identification listed above, you must provide:
suspended or you are disqualified from driving in any Australian state
or territory or any other country. 3 EOI documents + evidence of Qld residency. At least 1 EOI
document must show your signature.
The information you provide in this document must be true and (For a full list of acceptable EOI documents please see Evidence of
correct otherwise the licence granted to you will be void and you may Identity Requirements for Individuals (form F4362) or visit www.qld.gov.au)
be prosecuted for providing false or misleading information.
All EOI documents must be ORIGINAL and include:
If your application/renewal is approved, your licence will be mailed to 1 category A + 2 category B OR 2 category A + 1 category B.
you. This may take up to 2 weeks. You will receive a Driver Licence
Category A (e.g. passport, birth certificate, Australian photo driver licence)
Receipt today which will allow you to drive until you receive your
licence. Document Type Document number (e.g. X0100011)
Please PRINT clearly in dark pen (do not use pencil or erasable ink) Passport x1937511(e.g. C0100011)

1. Personal details Category B (e.g. Medicare card)

Family name Document Type Expiry date (if applicable)
Danastya
Given name/s Category A or B
Markista Wikan Document Type Document number or expiry date
Date of birth (do not give credit/debit card number)
dd
31 05 / 1994
/ mm yy Evidence of Qld residency address (e.g. bills for phone, electricity, rates)
Gender: Male (M) ✔ Document Type Issue date

Female (F) Bank account dd / mm / yy

Town, state and country of birth 4. Is your name different from the name on your current
Cutup, Brngkulu, Indonesia driver licence or EOI documents above?
Residential address No ✔ Yes You must show an EOI change of name document
Change of name document (e.g. Australian change of name certificate)
67 Everest Street, Sunnybank
Document Type Document number Issue date

dd / mm / yy
Postcode 4109
5. Do you have a driver licence issued by another
Postal address (if same as residential address, write ‘as above’)
Australian state or territory or country?
as above No ✔ Yes Fill in details below. If you have a licence
issued by another Australian state or territory,
you must surrender it to be eligible for a Qld
Postcode driver licence.
Licence/reference number Effective date
Daytime contact phone number
0434358179 dd / mm / yy
State/territory/country of issue Expiry date
Email address
[email protected] dd / mm / yy
Licence type (e.g. L/P/O) Licence class/es (e.g. C/LR/MR)
2. Previous name or aliases
Do you currently hold or have you ever been issued a Qld driver
licence, industry authority, marine licence, adult proof of age card
or vehicle/vessel registration, in any other name? (e.g. name at
6. Licence type and class
birth, maiden name, previous married names, adoptive name, or What type/class of licence(s) are you renewing or applying for?
other aliases) Licence Type Licence Class
No ✔ Yes Provide details below Learner Car ✔ C Light Rigid LR
Previous family name P Car (Automatic CA Medium Rigid MR
Condition)
P1 Learner Approved Heavy Rigid HR
RE
Motorbike
Previous given name/s P2 Heavy Combination HC
Motorbike ✔ R
Open ✔ Multi-combination MC

Note: An evidence of identity document linking your previous Are you applying for a licence or class of licence that you held
name and your current name may be required. more than 5 years ago?
No Yes ✔ You must provide evidence of your previous licence
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7. Medical Condition Reporting 10. Applicant’s declaration
You must report any medical condition/s that may adversely Sign only in the presence of an authorised person.
affect your ability to drive. I declare that I have read the answers I have given to the
a. Do you need to wear glasses/contact lenses for driving? questions in this application and that the answers are complete,
No ✔ Yes S condition will be shown on your licence true and correct in every detail.
b. Do you have any of the following conditions? Check each statement. If undertaking a practical driving test, I declare that I have the
consent of the registered operator to use the vehicle for the test.
No Yes I also declare that the registered operator has given consent for
Vision or eye disorder (other than wearing glasses any Driving Examiner employed by the department or any Police
or contact lenses) that may adversely affect your ✔ Officer, to drive the vehicle during or in connection with the test
driving undertaken in the vehicle, if required.
Diabetes that requires treatment by tablet, insulin or I understand that if I have stated anything that is false or
✔ misleading, the driver licence granted to me as a result of this
other medication
application will be absolutely void and have no legal effect
Been diagnosed with epilepsy, experienced a whatsoever.
seizure; or been required to take anti-epileptic ✔
medication after the age of 11 I understand that I may be prosecuted for giving or stating any
false or misleading information or documents.
Any other medical condition/s that is likely to
✔ I consent to the department taking, keeping and using my
adversely affect your ability to drive safely
personal information, documents, digital photo and digitised
If you have answered Yes to any statement at 7b, you must signature for the purposes associated with my application.
provide a Medical Certificate for Motor Vehicle Driver (form F3712) I consent to the department verifying my EOI or evidence of
completed by your treating doctor. previous licence provided by me with the issuing authority or their
8. Traffic history agencies.
a. Have you currently, or within the last 5 years, had your licence Additional declaration by interstate or overseas licence holders.
cancelled or been disqualified from driving or obtaining a driver
licence by an Australian or overseas court? I understand that by signing this declaration I agree to the
surrender of my interstate driver licence.
No ✔ Yes Provide details below
I also consent to the department releasing information about
Reason for cancellation/disqualification my application for a Qld licence to the issuing authority or their
agencies.
Applicant’s signature Date
dd / mm / yy

State/territory/country Duration It is an offence under the Transport Operations (Road Use Management)
Act 1995 to state anything or give a document to an authorised person
if you know it contains false or misleading information. The maximum
b. Is your licence currently suspended for any reason including penalty may be more than $7000.
speeding offences, demerit points, unpaid fines or any other
reason?
No ✔ Yes Provide details below
Reason for suspension

Authorising person’s checklist

EOI sighted - address and details current on system
State/territory/country Duration S or M conditions checked/added/amended
M condition reported - F3712 attached if required
9. Court Orders - restricted licence Court orders/restrictions - sighted and copies attached, codes added
Have you been granted a current court order for any of the O/S - licence/documents sighted, copied and attached if required
following? Check each statement.
O/S - translations of O/S document copied and attached if required
No Yes Code
Application Approved / Refused
A drink or drug driving conviction ✔ X1
Comments by authorising person
Special Hardship Order (SHO) ✔ X3
An order allowing you to drive until your drink or
✔ X4
drug driving charge is heard in court
If you have answered Yes to any of the above, you will need to
show your court order/s. The relevant code will be shown on your Authorising person’s declaration
licence. You must comply with the court order and carry it with you I have witnessed the applicant’s signature and checked that it
when driving. matches the applicant’s evidence of identity which I have sighted.
Privacy statement: The Department of Transport and Main Roads (the
department) collects this information under the provisions of the Transport Authorising person’s name
Operations (Road Use Management) Act and Transport Planning and
Coordination Act so that you may apply for a Qld driver licence. The department
may disclose this information to interstate and foreign driver licensing authorities,
and the Queensland Police Service (QPS). Your digital photo may also be Signature
released to the QPS. The department’s card production contractor will have
controlled access to your information, digitised signature and digital photo to
make your card. Information, including your digital photo or digitised signature, Office stamp / date
may be disclosed to an authorised agency if the information is connected to
an application for its product. Your information will not be disclosed to any
other third party without your consent, unless required or authorised by law.
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