NSW Photo Card Application

Important customer information

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 any motor registry. A list of suitable documents is also available on the RTA website at www.rta.nsw.gov.au. If none of your POI documents show a residential address or you cannot provide acceptable proof of address, the Reference statement at item 8 must 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's signature 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 the existing 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 notify the RTA in person at any motor registry as soon as practicable. Customer Number Office You must notify the RTA about any change of name or address within 14 days Use Only after the change. You must be at least 16 years old.

Attachments

Personal details Surname

Replacement NSW photo card What is the reason for your replacement NSW photo card? Lost

application

for

Poor card quality Not received Change of appearance Organ donor details change

Given names

Stolen Damaged/Destroyed

NSW Residential address

Personal details have changed 6

Postcode

Mailing address (if different from residential address)

Surrender Driver Licence or POA card If the card has been lost, stolen, damaged or destroyed you will be required to sign a lost, stolen, damaged or destroyed declaration. Driver Licence

Postcode NSW Licence/Customer number

(if available) Day

POA card 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 NSW Photo Card application and may retain and use it for driver licensing, motor vehicle and road transport or safety purposes. The RTA is entitled to obtain your personal information under the Photo Card Act 2005 and may refuse your application if you do not provide it. The RTA may disclose your personal information to assess your application or verify the information you provide. Otherwise the RTA will not disclose your personal information without your consent unless authorised by law. Your personal information will be held by the RTA at 101 Miller Street, North Sydney NSW 2060 and you can contact the RTA to request 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 for a NSW Photo Card by false statement, misrepresentation or other dishonest means. You cannot have a NSW Photo Card and NSW Driver Licence at the same time and you must surrender one before being issued with the other. If you are surrending a NSW Photo Card in order to apply for a NSW Driver Licence, the RTA may require medical evidence of your fitness to drive.

Date of birth

Month

Year

Sex: 2

male

female

Do you have a current NSW Pensioner Concession Card (PCC) or a Centrelink Confirmation of Concession Card Entitlement form stamped PCC or a Department of Veterans' Affairs (DVA) Gold Card endorsed TPI or EDA or 'War Widow' or 'War Widower', or a DVA letter or statement certifying a disability pension of 70% or more, or an intermediate pension or an assessment at 50 or more impairment points? No Yes
You may be entitled to a concession. If you answer yes evidence must be produced. Pensioner eligibility must be verified electronically with Centrelink.

I would like:

a NSW Photo Card

Now go to 4 Now go to 5

a replacement NSW Photo Card 4

Do you hold or have you ever held a licence to drive or ride in NSW or a NSW Photo Card/Proof of Age Card in the above name or another name? No Yes
Now go to 7 Give details below

Signature Expiry date Date

NSW Licence/Customer number, Photo Card/POA card number

Other name (if applicable)

Day

Month

Year

Now go to 6
Catalogue No. 45071151 RTA Form No. 1359 (12/2010) RTA ABN 64 480 155 255 Page 1 of 2

Reference
Required when you cannot provide proof of residential address. To be completed by a person who has known you for at least 12 months and holds a current NSW unrestricted Driver Licence. The RTA may contact the referee to verify information in this application. Referee's full name (please print)

(continued from previous column)

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

Witness full name (please print)

Referee's Driver Licence number

Referee's daytime contact telephone number

Witness Driver Licence number (if applicable)

Witness daytime contact telephone number

Witness address (home or work) Please note: If you do not tell the truth in your reference statement, both you and the applicant can be fined.
I declare that I have known the applicant for at least 12 months and that to the best of my knowledge, the personal details given in item 1 are correct. I understand that my personal information is being collected for verification of the applicant's personal details. My supply of a referee's statement is voluntary. The RTA may disclose my personal information inside and outside NSW to verify the contents of this application.

**Please read important privacy information at item 10. Signature of witness

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

Date
Day

**Please read important privacy information at item 10. Signature of referee

Month

Year

10 Important privacy information (please read)

Date
Day

Month

Year

Personal information, including any image, is collected and held by the Roads and Traffic Authority (RTA), 101 Miller Street, North Sydney NSW 2060. You have a right to access or correct your personal information in accordance with the provisions of the relevant privacy legislation. Organ donation consent - people helping people Organ donation is voluntary. If you consent to be an organ donor your decision will be shown on your Photo Card but you should also advise your next of kin and the Australian Organ Donor Register at Medicare. You can cancel or change that decision at any time by contacting a RTA motor registry. The RTA may use this information in relation to organ donation and disclose it to health and organ donation organisations. Otherwise the RTA will not disclose your personal information without your consent unless authorised by law. Are you willing to become an organ donor? Yes

Witness to applicant's signature

Required when you cannot: Provide an acceptable proof of identity document with your signature or, Leave your mark on this application or, Sign this application. If witnessed by a parent, guardian or carer they must attend the motor registry with you and show proof of their own identity. Name of applicant (please print)

Signature/mark of applicant OR

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

Witness declaration
I certify that the applicant whose name and signature/mark appear above has signed/marked in my presence. I certify that the applicant whose name appears above is unable to sign or mark this application for the following reason. Reason why applicant cannot sign this form No Signature

Kidneys Pancreas Heart and Lungs

Eye corneas Skin

Liver Bone

I wish to register my decision not to be an organ and/or tissue donor.

Date

(go to next column)

Day

Month

Year

Office Use

Proof of identity record

Document number Passport/Visa date of issue or E/D Secondary proof

Stand-alone or primary proof

POI for parent, guardian or carer Proof of residential address

Type of proof

Photo comparison
No stored image or not requested Matched Mismatched

Faulty

Failed to arrive on time

Card details (tick

First issue of Photo Card

applicable box)
Reissue/replacement Photo Card

(tick

applicable box)
NSW Driver Licence handed in or declared lost, stolen, damaged or destroyed NSW POA Card handed in or declared lost, stolen, damaged or destroyed

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

Verified by:
Name Signature CSO number or agency name Date
Day

Month

Year

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

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