Read F4208_ES (Update).FH11 text version

Queensland Residency Declaration

Adult Proof of Age Card Act 2008 Transport Operations (Road Use Management) Act 1995

This form may be used if you are required to give evidence of your Queensland (Qld) residential address and you are genuinely unable to provide suitable evidence of residential address documents.

1 Personal details

Residential address

Family name (Please PRINT) Given name/s Residential address

Postcode

Male Female

Daytime contact phone number

4. Verifying persons declaration

I declare that I have known the person making this declaration for a period of years. I declare that the person making this declaration ordinarily resides with me at the residential address stated on this declaration. I give permission for the authorising person to contact me for any further information considered necessary for the purpose of this declaration and agree to give any further information that the authorising person may ask for to verify any statement made by me in this declaration. I declare that, to the best of my knowledge, the information given by the person making this declaration is complete, true and correct. I declare that the information I have provided in this declaration is complete, true and correct in every detail. I give permission for the authorising person to access my record to confirm the information provided by me in this declaration.

Postal address (if same as residential, write AS ABOVE)

Daytime contact phone number Town and country of birth Height cms

Date of birth

Day

Month

Year

/

/

Verifying persons signature

Date

/

Eye colour Hair colour Complexion

/

2 Personal declaration

It is an offence under the Transport Operations (Road Use Management) Act 1995 and the Adult Proof of Age Card Act 2008 to state anything or give a document to an authorised person if you know it contains false or misleading information. Penalties apply.

Privacy Statement: The Department of Transport and Main Roads (the department) provides this form under the Transport Operations (Road Use Management) Act 1995 and the Adult Proof of Age Card Act 2008 to manage the Queensland driver licence, adult proof of age card and vehicle registers. This information is accessible by authorised departmental persons and the Queensland Police Service as allowed under the relevant transport Act and Adult Proof of Age Card Act 2008. Information about vehicle registrations may also be disclosed to vehicle insurers, lawyers, statutory and insolvency entities, persons involved in vehicle accidents/incidents, vehicle manufacturers and to or through interstate registering authorities. Driver licence and adult proof of age card information may also be disclosed to interstate agencies that issue adult proof of age cards as allowed under the relevant transport Act and the Adult Proof of Age Card Act 2008. The department will not disclose your personal information or documents to any other third parties without your consent unless authorised by law.

Sign only in the presence of the verifying person.

I declare that the information I have provided in this declaration is complete, true and correct in every detail. I understand that failure to provide complete, true and correct information in this declaration may result in my declaration being refused. I authorise the authorising person to make any enquiries considered necessary to verify the information provided by me in this declaration. I consent to the department taking, keeping and using my personal information and documents for the purposes associated with my driver licence and adult proof of age card as required under the Transport Operations (Road Use Management) Act 1995 and the Adult Proof of Age Card Act 2008 or otherwise authorised by law.

Signature

Date

/

/

Office use only

Confirmation of verifying statements checklist

On receipt of this completed form, the authorised person may confirm the verifying person's statements (if required) by telephoning the verifying person Verifying persons driver licence/APA card details confirmed in TRAILS/TICA Verifying persons residential address confirmed in TRAILS/TICA

It is an offence under the Transport Operations (Road Use Management) Act 1995 and the Adult Proof of Age Card Act 2008 to state anything or give a document to an authorised person if you know it contains false or misleading information. Penalties apply.

3 Verification of residential address

The following declaration must be completed by a person who - is at least 18 years of age, and - is a current Queensland driver licence or adult proof of age (APA) card holder, and - resides at the same address as you.

Decision

Has this declaration been accepted? Yes

Comments

Family name (Please PRINT) Given names

Verifying person's details

No

Authorising persons signature Driver licence/APA Card number Office stamp

Date / /

SSA Multimedia Services Form F4208 ES V01 Jan 2011

Information

F4208_ES (Update).FH11

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