Queensland Government - Driver License Application/renewal Page 2
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28. Are you currently or have you recently been disqualified
#Note 2: A Medical Certificate is required if your licence has an M condition
and your doctor has indicated you meet the criteria for an
from holding or obtaining a marine licence by an order of
unconditional licence.
an Australian or overseas court?
18.
Applicant’s declaration
No
Go to 9
Sign only in the presence of a departmental person.
Yes
State/Territory/Country
Length of disqualification
I declare that I have read the answers I have given to the questions in
this application and that the answers are complete, true and correct in
every detail. I understand that if I have stated anything that is false or
misleading, the driver licence granted to me as a result of this application
9. Are you currently or have you recently been disqualified
will be absolutely void and have no legal effect whatsoever. I understand
from holding or obtaining a driver licence by an order of
that I may be prosecuted for giving or stating any false or misleading
an Australian or overseas court?
information or documents. I consent to the department taking, keeping
No
Go to 10
and using my personal information, documents, digital photo and
digitised signature for the purposes associated with my application.
Yes
State/Territory/Country
Length of disqualification
I consent to the department verifying my EOI or evidence of previous
licence provided by me with the issuing authority or their agencies.
Additional declaration by interstate licence holders
10. Have you been granted a court order for any of the
I understand that by signing this declaration I agree to the surrender
following reasons? (Please show your court order)
of my interstate driver licence.
(a) Restricted licence order for a drink or drug driving conviction
Applicant’s signature
Date
Yes
No
Code X1 will be shown on your driver licence.
Day
Month
Year
/
/
(b) Special Hardship Order (SHO)
No
Yes
It is an offence under the Transport Operations (Road Use Management)
Code X3 will be shown on your driver licence.
Act to state anything or give a document to an authorised person if you
(c) s79E order for a drink or drug driving related offence
know it contains false or misleading information. The maximum penalty
may be more than $7000.
No
Yes
Code X4 will be shown on your driver licence.
19.
Registered operator’s authorisation for test vehicle
11. Has your licence been cancelled for any other reason?
I authorise any Driving Examiner employed by the department or any
Police Officer, to drive my vehicle during or in connection with any
No
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driving test undertaken in my vehicle, if required.
Vehicle registration number
Yes
Reason for cancellation
Registered operator’s signature
Date
State/Territory/Country
Period
Day
Month
Year
/
/
12. Is your driver licence currently suspended for any of the
Privacy Statement: The department collects this information under the provisions
following reasons?
of the Transport Operations (Road Use Management) Act and Transport Planning
and Coordination Act so you may apply for a Qld driver licence. The department may
Speeding offence
No
Yes
disclose this information to interstate and foreign driver licensing authorities, and the
Queensland Police Service (QPS). Your digital photo may also be released to
Give
Accumulation of demerit points
No
Yes
interstate driver licensing authorities and the QPS. The department’s card production
details
contractor will have controlled access to your information, digitised signature and
Unpaid fines
No
Yes
below
digital photo to make your card. Information, including your digital photo or digitised
Any other reasons
No
Yes
signature, 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
State/Territory/Country
Period
third party without your consent, unless required or authorised by law.
Office Use Only
Practical driving test results
13. Do you need to wear glasses/contact lenses for driving?
Class tested
Code/condition (if any)
No
Yes
S condition will be shown on your licence
Passed
Failed
14. Do you have any other vision or eye disorder?
Examiner’s signature
Date
Day
Month
Year
No
Yes
Medical certificate (form F3712) is required
/
/
Note: Your doctor may require a report from an Optometrist or
Examiner’s number
Report number
Ophthalmologist.
15.
Do you have diabetes?
No
Yes
How is your diabetes controlled?
Tick where applicable
Applicant’s details confirmed
Medical certificate (form F3712) is
Diet only
Applicant’s EOI confirmed
in TRAILS/TICA
not required
Insulin or other
1:1 match performed
Application approved
Medical certificate (form F3712) is
glucose-lowering
required (see Note 1*)
Returning driver-previous licence verified and recorded (if required)
agent
16.
Have you been diagnosed with epilepsy or experienced a
Application not approved
Give refusal letter
seizure at any time?
Comments
No
Go to 17
Have you experienced a seizure or been required to
Yes
Authorising person’s declaration
take anti-epileptic medication after the age of 11?
I declare that I witnessed the applicant’s signature. I am satisfied the
Medical certificate (form F3712) is
signature accords satisfactorily with the signature appearing on the EOI
No
Yes
document/s, if applicable. I also declare that I sighted the EOI, evidence of
required (see Note 1*)
Qld residency, change of name documents and evidence of previous licence
17. Do you have any other medical condition that is likely to
as required.
adversely affect your ability to drive safely?
Authorising person’s name
Medical certificate (form F3712) is
No
(See Note 2#)
Yes
required (see Note 1*)
Authorising person’s signature
Date
*Note 1: You and your doctor must also complete the Private and Commercial
Vehicle Driver’s Health Assessment (form F3195) if you hold or
Day
Month
Year
/
/
are applying for a licence to drive:
– a vehicle that is more than 8t GVM (class MR, HR, HC, MC)
– a public passenger vehicle (e.g. taxi, limousine, bus)
Office Stamp
– a vehicle carrying dangerous goods.
Page 2 of 2 TRB Forms Area F3000 CFD V01 Nov 2015
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