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NSW Photo Card Application

Important customer information

If none of your POI documents show a residential address or you cannot provide acceptable proof of address, the Reference statement at item 8must be completed.

If you do not provide a POI document that has your signature or cannot leave your mark or signature on this form, the Witness to applicant'ssignature at item 9 must be completed.

If you hold a NSW Photo Card and you are getting a replacement or being issued a new one because the old one has expired, you must hand in theexisting card.

If you hold a NSW Driver Licence or Proof of Age (POA) Card and you want a NSW Photo Card, you must hand in the Driver Licence or POA Card.A refund may be applicable on the remaining portion of your Driver Licence. There is no refund on the POA Card.

You must hand in your NSW Photo Card if you want a NSW Driver Licence. There is no refund on the NSW Photo Card.If your current Photo Card is lost, stolen, damaged or destroyed, you must notifythe RTA in person at any motor registry as soon as practicable.

You must notify the RTA about any change of name or address within 14 daysafter the change.

OfficeUse Only

Customer Number Attachments

1 Personal details

Surname

Given names

NSW Residential address

Mailing address (if different from residentialaddress)

NSW Licence/Customer number

Day Month / YearSex: male

3 a NSW Photo Card Now go to 4I would like:

a replacement NSW Photo Card Now go to 5

4 Do you hold or have you ever held a licence to drive orride in NSW or a NSW Photo Card/Proof of Age Card inthe above name or another name?

No Now go to 7

Yes Give details below

NSW Licence/Customer number,

Photo Card/POA card number

Other name (if applicable)

5

6 Surrender Driver Licence or POA card

If the card has been lost, stolen, damaged or destroyed youwill be required to sign a lost, stolen, damaged or destroyeddeclaration.

Driver Licence

7 Privacy statement and declaration

Please read carefully before you sign.If you do not tell the truth you can be fined.

The RTA is collecting your personal information for your NSWPhoto Card application and may retain and use it for driverlicensing, motor vehicle and road transport or safety purposes.

The RTA is entitled to obtain your personal information under thePhoto Card Act 2005 and may refuse your application if you do notprovide it.

The RTA may disclose your personal information to assess yourapplication or verify the information you provide.

Otherwise the RTA will not disclose your personal informationwithout your consent unless authorised by law.

Your personal information will be held by the RTA at 101 MillerStreet, North Sydney NSW 2060 and you can contact the RTA torequest 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 fora NSW Photo Card by false statement, misrepresentation or otherdishonest means.

You cannot have a NSW Photo Card and NSW Driver Licence atthe same time and you must surrender one before being issuedwith the other. If you are surrending a NSW Photo Card in order toapply for a NSW Driver Licence, the RTA may require medicalevidence of your fitness to drive.

Signature

Date

Catalogue No. 45071151 RTA Form No. 1359 (12/2010) RTA ABN 64 480 155 255 Page 1 of 2

(if available)

Date of birth

/

Replacement NSW photo card

female

Expiry date

What is the reason for your application for areplacement NSW photo card?

Lost

Stolen

Damaged/Destroyed

Poor card quality

Not received

Change of appearance

Organ donordetails change

Personal detailshave changed

POA card

Day Month / Year/

Now go to 6

To get a NSW Photo Card you must provide Proof of Identity (POI) documents. The brochure 'How to Prove Who You Are' is available from anymotor registry. A list of suitable documents is also available on the RTA website at www.rta.nsw.gov.au.

Postcode

Postcode

2 Do you have a current NSW Pensioner Concession Card(PCC) or a Centrelink Confirmation of Concession CardEntitlement form stamped PCC or a Department ofVeterans' Affairs (DVA) Gold Card endorsed TPI or EDAor 'War Widow' or 'War Widower', or a DVA letter orstatement certifying a disability pension of 70% ormore, or an intermediate pension or an assessment at50 or more impairment points?

No

Yes

You must be at least 16 years old.

You may be entitled to a concession. If you answeryes evidence must be produced. Pensioner eligibilitymust be verified electronically with Centrelink.

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(tick applicable box)

9 Witness to applicant's signature

Required when you cannot:

Provide an acceptable proof of identity document with yoursignature or,Leave your mark on this application or,

Sign this application.

If witnessed by a parent, guardian or carer they must attend themotor registry with you and show proof of their own identity.

Name of applicant (please print)

Signature/mark of applicant

Witness declaration

Reason why applicant cannot sign this form

Witness full name (please print)

10 Important privacy information (please read)

Stand-alone or primary proof Document number Passport/Visa date of issue or E/D Secondary proof

POI for parent, guardian or carer Proof of residential address

No stored image ornot requested

Matched Mismatched Faulty Failed to arrive on time

Verified by:Name Signature CSO number or agency name

Catalogue No. 45071151 RTA Form No. 1359 (12/2010) RTA ABN 64 480 155 255 Page 2 of 2

Personal information, including any image, is collected and held bythe Roads and Traffic Authority (RTA), 101 Miller Street, NorthSydney NSW 2060. You have a right to access or correct yourpersonal information in accordance with the provisions of therelevant privacy legislation.

Required when you cannot provide proof of residentialaddress. To be completed by a person who has known you for atleast 12 months and holds a current NSW unrestricted DriverLicence. The RTA may contact the referee to verify information inthis application.

Referee's full name (please print)

Referee's daytime contacttelephone number

Please note: If you do not tell the truth in your referencestatement, both you and the applicant can be fined.

I declare that I have known the applicant for at least 12 months and that tothe best of my knowledge, the personal details given in item 1 are correct.

I understand that my personal information is being collected for verification ofthe applicant's personal details. My supply of a referee's statement isvoluntary. The RTA may disclose my personal information inside and outsideNSW to verify the contents of this application.

(go to next column)

**Please read important privacy information at item 10.

Signature of referee

(continued from previous column)

I understand that my personal information is being collected for verification ofthe applicant's signature, mark or reason for not signing the application. I amacting as a witness voluntarily. The RTA may disclose my personalinformation inside and outside NSW to verify the contents of this application.

Witness Driver Licence number(if applicable)

Witness daytime contacttelephone number

Witness address (home or work)

**Please read important privacy information at item 10.

Position of witness

Employer / school principal /bank manager / parent / guardian/carer (circle applicable position)

Organ donation consent - people helping people

Organ donation is voluntary. If you consent to be an organ donor yourdecision will be shown on your Photo Card but you should also adviseyour next of kin and the Australian Organ Donor Register at Medicare.You can cancel or change that decision at any time by contacting a RTAmotor registry. The RTA may use this information in relation to organdonation and disclose it to health and organ donation organisations.Otherwise the RTA will not disclose your personal information withoutyour consent unless authorised by law.

Are you willing to become an organ donor?

Yes I consent, in the event of my death, to removal of any of my organs ortissues and will advise my next of kin of this decision.

OR I consent, in the event of my death, to removal of the organs or tissuesindicated only, and will advise my next of kin of this decision.

Liver

BoneSkinPancreas

No I wish to register my decision not to be an organ and/or tissue donor.

Eye corneasKidneys

Heart and Lungs

Signature of witness

Signature

Type of proof

8 Reference

Photo comparison

Office Use Proof of identity record

Card details (tick applicable box)

First issue ofPhoto Card

Reissue/replacementPhoto Card

Referee's Driver Licence number

I certify that the applicant whose name and signature/markappear above has signed/marked in my presence.

I certify that the applicant whose name appears above isunable to sign or mark this application for the following reason.

NSW Photo Card handed inor declared lost, stolen,damaged or destroyed

NSW Driver Licence handed inor declared lost, stolen,damaged or destroyed

NSW POA Card handed inor declared lost, stolen,damaged or destroyed

Day Month/

Year

Date

/

Day Month / Year

Date

/

Date

Day Month / Year/

Day Month / Year

Date

/