Change of Customer Details (Individual)
Photo Identication Card Act 2008; Tow Truck Act 1973; Transport Operations (Marine Safety) Act
1994; Transport Operations (Passenger Transport) Act 1994; Transport Operations (Road Use
Management) Act 1995; Transport Planning and Coordination Act 1994
Evidence of Identity (EOI) Requirements
You must give evidence of your identity. You may do so by showing
your Queensland (Qld) driver licence, industry authority, marine
licence indicator (conditions apply), adult proof of age card (APA
card) or photo identication (Photo ID) card. All cards must be
current or expired by less than two years. If you are unable to do this,
you will need to present three other acceptable EOI documents and
evidence of your Qld residential address.
If you have changed your name or the details of your name are
different on the documents provided, you must show a change of
name document from the relevant Australian Register of Births,
Deaths and Marriages (BDM).
For a full list of acceptable EOI, evidence of residential address and
change of name documents, please refer to the Evidence of Identity
Requirements for Individuals (form F4362) or visit www.qld.gov.au.
Page 1 of 2 TRB Forms Area Form F4214 CFD V01 Apr 2019
Please use this form to change your name or address, or any other
personal details you have given to the Department of Transport and
Main Roads. These changes will be recorded against all relevant
products you hold (for example, driver licence, industry authority,
marine licence and vehicle registration).
If you are transferring the registration of your vehicle, you must use
the Transfer of Vehicle Registration Application (form F3520). If
you are transferring a recreational ship registration, you must use the
Recreational Ship Registration Transfer Application (form F3521).
1. Personal details (as currently recorded)
Family name
Email address
Given name/s
Male (M)
No
Would you like to get e-notices and e-reminders?
Female (F)
Yes
Residential address
Postcode
Postal address (if same as residential, write ‘as above’)
Postcode
2. Can you show your Qld driver licence, industry authority,
marine licence indicator, APA or Photo ID card?
Yes
No
Licence/authority/reference number
You are required to show three EOI documents and
one evidence of residential address document. Please
provide details of your documents.
3. Have you changed your name?
No
Yes You are required to show an EOI change of name
document. Please provide details of your documents.
Change of name
4. Have you changed your address?
Section A - Customer Details
Daytime contact phone number Date of birth
/ /
New family name
New given name/s
No
Yes New residential address
Go to question 4
Go to question 5
Postcode
New postal address (if same as above, write ‘as above’)
Postcode
New garaging address for vehicle
Postcode
Category B (please print)
Category A or B (please print)
Evidence of Qld residential address (please print)
No Yes
5. Have you changed any other personal details?
Provide details
Town, state and country of birth
Document type
(for example Medicare card)
Expiry date
(if applicable)
Document type
Document number or expiry date
(do not give credit/debit card
number)
Document type
(for example telephone account)
Issue date
(for example 10/06/2015)
Driver licence (complete Section B)
6. Products to be changed
Driver licence with marine licence indicator (complete
Section B and D)
Industry Authority (complete Section C)
Marine licence indicator (complete Section D)
APA or Photo ID card (go straight to Applicant’s Declaration)
Category A (please print)
Document type
(for example Qld BDM birth certicate)
Document number
(for example X0100011)
Vehicle
registration
Plate number/s
Other authorised product (complete Section E)
Ship
registration
Registration number/s
Document type
(for example Qld BDM
issued Marriage Certicate)
Document number
(for example 01000)
Registration year
(for example 2001)
Gender:
/ /
Privacy Statement: The department collects this information under the provisions
of the Acts nominated on this form to manage the Qld driver licence, industry
authority, marine licence, APA, Photo ID, vehicle and vessel registers or to issue
a product on behalf of an authorised agency. The department may disclose this
information and your digital photo to the Queensland Police Service. Information
about a driver licence may be disclosed to interstate and foreign driver licensing
authorities. Information about an APA or Photo ID card, pilot or escort vehicle driver
accreditation, driver or rider trainer accreditation, trac controller accreditation,
dangerous goods vehicle driver licence, or marine licence may be disclosed to
interstate authorities that issue the relevant card, accreditation or licence. The
department’s card production contractor will have controlled access to your
information, digitised signature and digital photo to make your card. Information
about your vehicle and vessel registration may be disclosed to interstate vehicle
and vessel registration authorities. Information, including your digital photo or
digitised 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 third party without your consent, unless required or authorised by law.
Applicant’s declaration
I declare that I have read all the answers I have given to the questions in
this application and that the answers given by me are complete, true and
correct in every detail. I understand that if I have stated anything in this
application that is false or misleading, the document granted to me as a
result of this application will be absolutely void and have no legal effect
whatsoever. I understand that I may be prosecuted for giving or stating
any false or misleading information or documents. I consent to the
department taking, keeping and using my information, documents, digital
photo and digitised signature for the purposes associated with my driver
licence, industry authority, marine licence indicator, APA or Photo ID
card, or to issue a product on behalf of an authorised agency, as required
under the relevant transport Acts and the Photo Identication Card Act or
otherwise authorised by law. I consent to the department verifying my
EOI documents or information provided by me with the issuing authority
or their agencies.
Applicant’s signature Date
/ /
Authorising person’s checklist (tick where applicable)
Applicant’s details conrmed
in TRAILS/TICA
Application approved
Application not approved
Applicant’s EOI conrmed
1:1 match performed
Comments by authorising person
Section B - Driver Licence
7. Are you currently disqualied from holding or obtaining
a driver licence by order of an Australian or overseas
court?
No Yes
Give details below.
State/Territory/Country
Length of disqualication
8. Have you recently completed a period of disqualication?
No Yes
Give details below.
State/Territory/Country
Length of disqualication
9.
Has your driver licence been cancelled for any other reason?
No Yes
Give details below.
State/Territory/Country
Length of disqualication
Reason for cancellation
10. Is your driver licence currently suspended for any of the
following reasons?
No
No
Yes
Yes
Speeding offence
Speeding offence
No
No
Yes
Yes
Give
details
below.
Give
details
below.
Accumulation of demerit points
Accumulation of demerit points
No
No
Yes
Yes
Unpaid nes
Unpaid nes
No
No
Yes
Yes
Any other reasons
Any other reasons
State/Territory/Country
State/Territory/Country
Length of suspension
Length of suspension
Section C - Industry Authority
11. Are you currently disqualied from holding or obtaining
a driver licence by order of an Australian or overseas
court?
No Yes
Give details below.
State/Territory/Country
Length of disqualication
12.
Have you recently completed a period of disqualication?
No Yes
Give details below.
State/Territory/Country
Length of disqualication
Section D - Marine Licence
15. Are you currently disqualied from holding or obtaining
a marine licence by order of a Qld court?
No Yes
Give details below.
State/Territory/Country
Length of disqualication
16. Do you require a digital photo and digitised signature to
apply for another agency’s product (e.g. a high risk work
licence)?
Applicant’s new signature
Date
/ /
It is an offence under the relevant transport Acts and the Photo
Identication Card Act to state anything or give a document to
an authorised person if you know it contains false or misleading
information. Penalties apply.
13. Has your industry authority been cancelled for any
other reason?
No Yes
Give details below.
State/Territory/Country
Length of disqualication
Reason for cancellation
14. Is your industry authority currently suspended for any
of the following reasons?
Authorising person’s declaration
I am satised the applicant’s signature matches the applicant’s EOI
documents which I have sighted.
Authorising person’s signature Date
/ /
Authorising person’s name
Ofce Stamp
Page 2 of 2 TRB Forms Area Form F4214 CFD V01 Apr 2019
Section E - Other Authorised Product
No Yes
Give details below.
Product name
If you have changed your name, please record your new
signature.