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, trac 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 Identication 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 conrmed
in TRAILS/TICA
Application approved
Application not approved
Applicant’s EOI conrmed
1:1 match performed
Comments by authorising person
Section B - Driver Licence
7. Are you currently disqualied 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 disqualication
8. Have you recently completed a period of disqualication?
No Yes
Give details below.
State/Territory/Country
Length of disqualication
9.
Has your driver licence been cancelled for any other reason?
No Yes
Give details below.
State/Territory/Country
Length of disqualication
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 disqualied 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 disqualication
12.
Have you recently completed a period of disqualication?
No Yes
Give details below.
State/Territory/Country
Length of disqualication
Section D - Marine Licence
15. Are you currently disqualied from holding or obtaining
a marine licence by order of a Qld court?
No Yes
Give details below.
State/Territory/Country
Length of disqualication
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
Identication 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 disqualication
Reason for cancellation
14. Is your industry authority currently suspended for any
of the following reasons?
Authorising person’s declaration
I am satised the applicant’s signature matches the applicant’s EOI
documents which I have sighted.
Authorising person’s signature Date
/ /
Authorising person’s name
Ofce 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.