Fillable Form F4101 Cfd - Conditional Vehicle Registration Transfer Application (Page 3 of 4) in pdf

Conditional Vehicle Registration

Transfer Application

Transport Operations (Road Use Management) Act 1995

Warning: If you reasonably believe the acquirer has not applied for transfer of the vehicle’s registration within 14 days,

you may lodge the ‘Sellers Copy’ with the Department of Transport and Main Roads. You may be held responsible for

offences committed by the acquirer/s until their details are recorded with the department.

Seller’s Copy

Part B. Proof of Transfer/Notice of Disposal: seller to keep

1. Vehicle details

5. Second registered operator’s details

Registration/Plate number

Issue date

Note: If the vehicle is being transferred to the name of a business/trust, you

must nominate one proprietor/trustee of the business or trust as the second

registered operator.

Do you have a CRN?

2. The vehicle is to be transferred from:

Complete a New Customer Application (F3503).

Note: If registered in joint names, all disposers’ details must be completed

below.

CRN

Yes

First disposer’s details

Disposer’s Customer Reference Number (CRN)

Full name

The CRN is your Queensland Driver Licence number, Adult

Proof of Age Card number or your reference number issued

6. Date of disposal

by the department.

Disposer’s name

7. Declaration

(All acquirer/s must sign, however, future

transactions will require only one signature).

Second disposer’s details

(if applicable)

I/We declare that the information provided is correct.

Disposer’s CRN

I/We consent to the department verifying my EOI

documents or information with the issuing authority or their

agencies.

Disposer’s name

Acquirer/s signature/s

3. Acquirer’s identification details

As the disposer of this vehicle, you must positively identify

the person who will now be responsible for the vehicle.

Date

The vehicle is to be transferred to:

First registered operator’s details

Full name and residential/business address

Disposer/s signature/s (if currently in joint names the

signature of only one disposer is required)

Postcode

Postal address (if same as street address write ‘as above’)

Date

Postcode

It is an offence to give false or misleading information under

Does the above individual or organisation have a CRN?

the Transport Operations (Road Use Management) Act.

Complete a New Customer Application (F3503).

Maximum penalty may exceed $7000.

Yes

CRN

Privacy Statement: The department is collecting the information on this form

for the purposes of maintaining the department’s vehicle/vessel registration

The registered operator above is: (tick one box)

private/

registered

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Act. The department or its agents/contractors may use your information in its

communications with you and where relevant, may give some of the information

individuals

company

to vehicle insurers, statutory entities, insolvency entities, lawyers, persons

business/

other/legal

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involved in vehicle accidents/incidents, vehicle manufacturers, third parties

trust

entities

who are involved in or intend to commence legal proceedings, tolling entities,

law enforcement agencies and interstate registering authorities. Your personal

4. Is the vehicle to be transferred into two names?

information will not be disclosed to any other third party without your consent

unless authorised or required to do so by law.

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Yes

Page 3 of 4 TRB Forms Area Form F4101 CFD V01 Nov 2015

Form F4101 Cfd - Conditional Vehicle Registration Transfer Application Page 3

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