Application For A Replacement Card Form
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1Western Australian Recreational Skipper’s Ticket
Application for a Replacement Card Form
This form must be signed and returned by post, fax, email or in person to:
In PERSON
By POST
By FAX
Fremantle Office
Hillarys Office
Geraldton Office
RST Officer
RST Officer
1 Essex Street
86 Southside Drive
65 Chapman Road
Department of Transport
(08) 9435 7817
Fremantle, WA 6959
Hillarys, WA 6025
Geraldton, WA 6530
PO BOX 402
By Email
Fremantle, WA 6959
rst@transport.wa.gov.au
OFFICE USE ONLY
Applicant’s Details
Receipt #:
£££££££
WA Motor Driver’s Licence Number:
Officer Name:
£££££££
RST Number (if known):
Surname: _________________________First Name: ___________________ Other Names:________________________
Sex: __________ Date of Birth:___________________ Email: _________________________________________________
dd-mm-yyyy
Street Number/Lot: __________ Street Name: ______________________________________ Street Suffix: _________
Suburb: ______________________________________________________________________Postcode: ____________
Telephone Home: _______________________Work: _____________________ Mobile: __________________________
PO Box: ____________________________________________ Suburb: __________________Postcode: ____________
Applicant’s Declaration
I ________________________________________________________(name in block letters), hereby declare that the particulars entered
in this application are correct and true to the best of my knowledge and belief, and that the Certificates and Testimonials submitted
with this application for verification of particular entries are true and genuine documents given and signed by the persons whose
names appear on them. I understand that some or all of the information provided on this form may be disclosed to Government
Authorities. A person who knowingly makes a false declaration, false statement or false representation in connection with this
application is guilty of an offence under Section 120(a) Western Australian Marine Act 1982.
Signature: ________________________________________________Date: _________________________________________________
OFFICE USE ONLY
Payment Details
Please tick (✓) the box to indicate the payment method.
Receipt #:
£
I wish to pay by Credit Card
£
I wish to pay by Cheque/Money Order
£
I wish to receive a call-back to make a Credit Card payment over the phone. Call-back Phone No. ______________________
Complete this section if paying by Credit Card
£
Mastercard
£
VISA
££££ ££££ ££££ ££££
Card Number:
Card Holder Name (please print): ___________________________________________________________________________________
Expiry Date: ________________________________________________________________ Amount:
$20.00
Signature: __________________________________________________________________ Date: _______________________________
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