Application For Mutual Recognition Of Public Passenger Or Driving Instructor Registration Form - Western Australia Department Of Transport Page 2
ADVERTISEMENT
1
2Section 5 - Statutory Declaration
(to be signed in the presence of an Authorised Officer)
I, _____________________________________________________ (full name) _________________________________ (occupation)
of _________________________________________________________________________________________ (residential address)
do solemnly and sincerely declare that:
1.
The statements and information provided in this notice are complete, true and correct in every detail;
2.
Any registration document attached is the original or a complete and accurate copy of the original;
3.
I consent to the making of inquiries and the exchange of information with the authorities of any State or Territory regarding
my activities relating to taxi/ bus driving or driving instruction and any matters relating to my eligibility to drive.
This declaration is true and I know that it is an offence to make a declaration knowing that it is false in a material particular.
I make this solemn declaration by virtue of the Oaths, Affidavits and Statutory Declarations Act 2005.
LOCATION AT WhICh DECLARATION WAS SIGNED (INCLuDE STATE/ TERRITORY)
DatE
/
/
DECLARANT’S NAME (PLEASE PRINT)
SIGNATuRE OF DECLARANT
DECLARED BEFORE ME (WITNESS SIGNATuRE)
AuThORISED WITNESS NAME AND OCCuPATION (PLEASE PRINT)
AuTHoriSeD WiTNeSS
The declaration on the back of this form must be made before any of the following persons:
1.
Academic (Post-Secondary institution)
21.
lawyer
41.
Surveyor
2.
Accountant
22.
local Government ceo or Deputy ceo
42.
Teacher
3.
Architect
23.
local Government councillor
43.
Tribunal Officer
4.
Australian Consular Officer
24.
loss Adjuster
44.
veterinary Surgeon
5.
Australian Diplomatic Officer
25.
marriage celebrant
6.
bailiff
26.
member of Parliament
Any other authorised person under the
7.
bank manager
27.
minister of religion
Statutory Declarations Act 1959 of the
8.
chartered Secretary
28.
Nurse
commonwealth
9.
chemist
29.
optometrist
10.
chiropractor
30.
Patent Attorney
11.
company Auditor or liquidator
31.
Physiotherapist
12.
Court Officer
32.
Podiatrist
13.
Defence Force Officer
33.
Police Officer
14.
Dentist
34.
Post Office Manager
15.
Doctor
35.
Psychologist
16.
engineer
36.
Public Notary
17.
commonwealth industrial organisation
37.
Public Servant (State or commonwealth)
18.
Secretary.
38.
real estate Agent
19.
insurance broker
39.
Settlement Agent
20.
Justice of the Peace
40.
Sheriff or Deputy Sheriff
oFFice uSe oNly
DATE:
WA MDL NO:
APPLICATION ASSESSED BY:
‘T’ extension approved
TAxI / BuS GOvT REGuLATOR
PREvIOuS EMPLOYER
‘F’ extension approved
‘DI’ authorisation approved
Medical Expiry Date __________________________
Mutual Recognition Application:
Approved
NEPI/Crim/Traffic Approved by __________________
Refused
Response from Govt Regulator attached
Response from previous employer attached
Reason:
Confirmed that applicant is not subject to unresolved complaints or disciplinary proceedings.
Date Applicant Notified:
Copy of notification letter attached
Confirmed Interstate Bus/Taxi Driver or Driving Instructor Authority was current/valid at time of application.
Please complete, PRINT and return signed copies
Reset form
ADVERTISEMENT
0 votes
Related Articles
Related forms
Application For Permit To Mix, Blend And/or Distributealcohol-gasoline Blends Form - Mississippi Department Of Agriculture And Commerce
Legal
Application For Class I, Ii & Iii Owts Designer's License Exam Form - Rhode Island Department Of Environmental Management
Legal
Application For A Winding Engine Driver's Certificate Of Competency - Western Australia Department Of Mines And Petroleum
Legal
Form 20 Notice To Tenant Of Breach Of Agreement - Government Of Western Australia, Department Of Commerce 2013
Legal
Related Categories
Parent category: Legal