Forms
Schedule 1 Forms
[r. 3 and 4]
[Heading inserted: Gazette 30 Jan 2001 p. 619.]
Form No. 1
Western Australia
Motor Vehicle Drivers Instructors Act 1963
APPLICATION FOR LICENCE UNDER THE MOTOR VEHICLE DRIVERS INSTRUCTORS ACT
INFORMATION FOR APPLICANT:
7 types of driving instructors’ licences are issued as follows —
No. | Classes of motor vehicle for driving tuition | |
1. | R | A motor cycle or a motor carrier. |
2. | C | A motor vehicle, other than a motor cycle or motor carrier, that has a GVM not exceeding 4.5 t and that is equipped to seat not more than 12 adults including the driver. |
3. | LR | A motor vehicle, other than a motor cycle or motor carrier, that — (a) has a GVM not exceeding 4.5 t and that is equipped to seat more than 12 adults including the driver; or (b) has a GVM exceeding 4.5 t but not exceeding 8 t. |
4. | MR | A motor vehicle, other than a motor cycle or motor carrier, that has 2 axles and a GVM exceeding 8 t. |
5. | HR | A motor vehicle, other than a motor cycle or motor carrier, that has 3 or more axles and a GVM exceeding 8 t. |
6. | HC | A motor vehicle that is attached to — (a) a semi‑trailer; or (b) a trailer that has a GVM exceeding 9 t. |
7. | MC | Any other motor vehicle. |
IMPORTANT — An applicant must have held an appropriate type of driver’s licence for at least 3 years and must be at least 21 years of age.
APPLICATION:
Mr.
I, Mrs................................................ ........................................................
Miss Christian names (in full) Surname (block letters)
of ............................................................................................................................
(Insert full residential address)
hereby apply for a type ..................... motor vehicle driving instructor’s licence. (Insert 1, 2, 3, 4, 5, 6 or 7 — see above)
I declare that the questions overleaf have been read by me and that the answers to such questions were written by me and, to the best of my knowledge and belief, are correct.
Date .........................................
Signature of Applicant ...................................
CERTIFICATE BY OFFICER RECEIVING APPLICATION
I certify that —
The declaration above has been read and signed by the applicant in my presence.
I have impressed upon him that such questions must be answered fully and correctly.
I have inspected the licence mentioned in the answer to Question 1 overleaf and have verified that the answers given in Items (a), (b) and (c) correspond with particulars on such licence.
Date ....................................
Signature ............................................
SEE OVER.
CAUTION: Any person who by false statement or misrepresentation obtains or attempts to obtain a licence, renders himself liable to a penalty of FIVE HUNDRED DOLLARS ($500), and any licence so obtained may be cancelled.
The answer to each of the following Questions 1 to 10 must be written by the applicant.
1. Have you been, or are you now, the holder of a licence, issued in Western Australia or elsewhere, to drive a motor vehicle? ................................................ | ........................... |
If so, please state — | |
(a) the name of the State or Country where the licence was issued .............................................. | (a) ..................... |
(b) the number of the licence and, if licence issued in Western Australia, the class of the licence ..... | (b) ..................... |
(c) the date of expiry of the licence ......................... | (c) ..................... |
Note — The licence must be produced for inspection by the officer receiving the application.
2. Are your Christian names, surname and residential address correctly stated overleaf? .............................. | ........................... |
How long have you lived at the address? If less than 6 months, give previous addresses .......... | ........................... |
3. What is the date and place of your birth? Date .............. Place ..................
4. (a) What is the name and address of your employer(s) during the last 6 months? ............... | (a) ..................... |
(b) In what capacity were you employed? ............... | (b) ..................... |
(c) When and for how long did you work for him/them? ........................................................... | (c) ..................... |
5. Have you successfully completed a course of training or passed a qualifying examination as a motor vehicle driving instructor? ............................... | ........................... |
If the answer is “Yes” full particulars must be shown | ........................... |
6. What are the names and addresses of two (2) persons who have known you personally and well for at least 12 months to whom references can be made as to your character? ........................................................... | ............................................................................................................ |
(NOTE — THE NAMES OF RELATIVES (INCLUDING A DE FACTO PARTNER) AND IMMEDIATE PAST EMPLOYERS SHOULD NOT BE FURNISHED. | ................................................................................. |
The names furnished should be those of persons resident in Western Australia and such as clergymen, postmasters, school teachers, bank managers, business or professional men, police officers, senior officers of the Public Service, or householders who have been residing at their present addresses for more than 12 months.) | .................................................................................................................................................................. |
“Yes” or “No” | If answer is “Yes” state type of visual aid used | |
7. Do you wear spectacles or contact lenses as a visual aid? .................... | .......................... | ........................... |
“Yes” or “No” | Particulars if answer is “Yes” | |
8. Do you suffer, or have you at any time suffered from — | ||
(a) Epilepsy or fits? ..................... | (a) .................... | ........................... |
(b) Frequent fainting or giddy attacks? .................................. | (b) .................... | ........................... |
(c) (i) Diabetes? ..................... | (c) (i) .............. | ........................... |
(ii) If so, are you being treated with insulin or any other substance to reduce blood sugar? .... | (ii) .............. | ........................... |
(d) Any permanent disability to either hand or arm, either foot or leg, or either eye, or from deafness? ................................ | (d) ................... | ........................... |
(e) Any physical disability likely to affect your efficiency in controlling a motor vehicle? .. | (e) ................... | ........................... |
9. Have you ever, in Western Australia or elsewhere — | ||
(a) been refused or disqualified from obtaining a licence as a driver or rider of a motor vehicle, or as a motor vehicle driving instructor; or | (a) ................... | ........................... |
(b) having held such a licence, had it suspended or cancelled? | (b) ................... | ........................... |
(If the answer to any portion of questions 8 and 9 is “Yes”, full particulars must be furnished.) | ||
“Yes” or “No” | Particulars if answer is “Yes” | |
10. Have you ever, in Western Australia or elsewhere, been convicted of — | (a), (b) and (c) must each be answered “Yes” or “No”. | |
(a) Drunkenness? ......................... (b) Driving a motor vehicle whilst under the influence of intoxicating liquor? ................ (c) ANY OTHER OFFENCE? .... | (a) ................... (b) ................... (c) ................... | If the answer is “Yes” to (a) or (b) or (c) particulars of every case as well as the courts and dates must be stated below. |
........................................................................................................................ ........................................................................................................................ | ||
[Form 1 amended: Gazette 5 Sep 1968 p. 2685; 28 Jun 1973 p. 2451; 30 May 1975 p. 1605; 9 Jul 1976 p. 2368; 2 Feb 1982 p. 397; 24 May 1985 p. 1764; 10 Aug 1990 p. 3906; 20 Sep 1991 p. 4943; 27 Apr 2001 p. 2205‑6; 30 Jun 2003 p. 2618.]
Form No. 2
Western Australia
Motor Vehicle Drivers Instructors Act 1963
LICENCE
MOTOR VEHICLE DRIVING INSTRUCTOR’S LICENCE
Licence No. ..........................................
Name ......................................................................................................................
Address ..................................................................................................................
Date of Birth ..........................................................................................................
Signature of Licensee ......................................................
Unless sooner cancelled or suspended this licence remains in force until.........................................................................................................................
This licence is subject to any conditions endorsed hereunder and authorises the holder to act as a driving instructor in respect of —
* all classes of motor vehicles
* motor vehicles of the following class or classes:
............................................................................................................
............................................................................................................
Conditions: ........................................................................................
............................................................................................................
Fee $22.60 (one year).
..........................................................
Director General
* Delete whichever inapplicable.
[Form 2 inserted: Gazette 9 Jul 1976 p. 2368; amended: Gazette 16 Feb 1979 p. 426; 18 Dec 1981 p. 5193; 2 Feb 1982 p. 397; 20 Aug 1982 p. 3269; 26 Sep 1986 p. 3689; 8 Sep 1989 p. 3174; 7 Sep 1990 p. 4700; 24 May 1996 p. 2170; 31 Jan 1997 p. 674; 13 May 1997 p. 2344; 12 May 1998 p. 2797.]
[Form 3 deleted: Gazette 9 Jul 1976 p. 2368.]
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