UPGRADE OF DRIVER LICENCE FOR RIDESHARE

AND

DRIVER ACCREDITATION AND VEHICLE LICENCE APPLICATION PACKAGE

(Including Renewal)

November 2017

Application for a Rideshare

Driver / Vehicle Licence in the ACT

Who should Complete and Submit this Application

The driver of a rideshare vehicle.

Eligibility requirements • You must be a permanent Australian resident or have a visa that allows you to work in Australia.• You must hold a full ACT driver licence.• The vehicle used to provide the rideshare service must be classed as a passenger carrying vehicle.

Vehicles classed as goods carrying vehicles cannot be used to provide a rideshare service.• The vehicle will be required to pass an ACT roadworthy from any authorised inspection station upon

application and annually thereafter.• The nominated registered operator of the vehicle must have a public passenger vehicle insurance

policy for at least $5,000,000.• The vehicle must registered with the appropriate Compulsory Third Party Insurance class.

Information you will need to lodge with this application • A copy of your ACT Drivers Licence.• A copy of either your:

o Australian Birth Certificate issued by Births, Deaths and Marriages (not commemorative); oro Australian Passport; oro Overseas Passport.

• A current Working with Vulnerable People registration card (Information on how to obtain Workingwith Vulnerable People registration can be found athttps://www.accesscanberra.act.gov.au/app/answers/detail/a_id/1804/kw/wwvp).

• A completed Commercial Drivers Health Assessment.• A completed ‘Authorisation to Release Public Passenger Driver Licence and Accreditation Status’

form,• A completed ‘Application for a Rideshare Vehicle Licence’ Form (only to be submitted if the driver Is

Not the nominated registered operator of the vehicle).• A copy of the Public Liability Insurance Policy for the vehicle (this must be in the registered operator’s

name and endorsed for Rideshare);

Payment

Rideshare Driver/Operator Accreditation Application Fee A $50 accreditation application fee is payable at the time of lodgement. The application fee will not be refunded should an application for accreditation be unsuccessful.

Rideshare Vehicle Licence Fee The Rideshare Vehicle Licence fee is $100 (due annually) or $450 (for 6 years) and is also payable at time of lodgement.

Payments must be made online at: https://form.act.gov.au/smartforms/transport/public-transport-payments

Applications and supporting documents can be:

emailed to: lara@act.gov.au OR mailed to: Manager Licence Registration Access Canberra PO Box 582 Dickson ACT 2602

If your application is approved

If your application is approved you will be notified and will need to attend an Access Canberra Service Centre to:

• Upgrade your licence to include a ‘D’ (Rideshare) condition and be issued with a PublicVehicle Driver Authority Card.

• Upgrade the registration CTPI class to ‘Rideshare’. The CTPI class can only be changed bya registered operator of the vehicle or an Act as an Agent form has been completed bythe owner.

Note: you will need to provide your ACT driver’s licence and a passed roadworthy inspection certificate (if applicable).

Once you have obtained the ‘D’ condition on your licence AND upgraded the registration CTPI class, Public Transport Regulation will process your rideshare driver accreditation and vehicle licence application and your Accreditation Certificate and the Vehicle Licence will be posted to you.

Note: If the rideshare driver is NOT the nominated registered operator of the vehicle to be used to provide the rideshare service then the nominated registered operator must also complete an ‘Application for a Rideshare Vehicle Licence’ and that form must be lodged with this Application.

Service Standards The Service Standards attached in this package set out the minimum requirements for the operation of a rideshare service. The accredited driver and licence holder must demonstrate compliance with the Service Standards by implementing procedures and processes which address all of the sections of the Standards and ensure that information and processes are auditable.

Further information Please call Access Canberra on 13 22 81 or visit www.act.gov.au/accessCBR for further information.

Privacy Statement: The information on this form is being collected for driver licensing purposes. The information may be used by the Road Transport Authority for the purpose of any of its statutory functions. The information may be disclosed to Commonwealth, Territory or State law enforcement agencies; transport authorities; government agencies authorised by law; Compulsory Third Party Insurers; and individuals, their agents or insurers following a report provided to the police of a motor vehicle accident. The Road Transport Authority is authorised to retain a digital copy of your photograph and signature under Part 4 of the Road Transport (Driver Licensing) Act 1999. Retained images may be used to assist in addressing identity fraud and disclosed to law enforcement and court agencies, interstate road authorities, or when authorised by law. The Information Privacy Act 2014 prevents the ACT Government from using your information and retained images for any unauthorised purpose and require it to implement safeguards to protect the information and retained images from unauthorised access.

10,029 (11/2017)

Application for Upgrade of Driver Licence

Licence details

National Heavy Vehicle driver licence applicants only

Driver licence number Class Date first issued State/Territory/Country of issue Staff verification

Important Information • Applicants for a public vehicle licence are required to undergo a Commercial Drivers Health Assessment, and hold a current Working with

Vulnerable People registration. Information on how to obtain registration can be found at www.act.gov.au/accessCBR.• Where a Public Vehicle Licence is issued, a Public Vehicle Driver Authority Card will also be issued to the licence expiry date.• If the applicant for an ‘O’ licence is to remain within their current licence class (e.g. C, LR, MR, HR, HC, MC) the applicant will be exempt from

the practical driving assessment.

Eye colourPlace of birth Height

I wish to apply for a (please tick appropriate box)LR Light rigid vehicle licence MR Medium rigid vehicle licence HR Heavy rigid licenceHC Heavy combination vehicle licence MC Multi-combination vehicle licence H Hire CarM Hire Car Motorcycle W Restricted Hire Car O Public BusT Taxi D Rideshare

Personal details

Residential address

Other namesSurname Given name

Date of birth Business hours phone number E-mail address

Declaration

Signature of applicant Date

Consent: I provide consent for the Road Transport Authority (RTA) to confirm my visa status with the Department of Immigration and Border Protection. I understand that this consent, once signed, is effective for the entire period in which I hold an ACT Driver Licence and may be used periodically by the RTA.

I declare that I am able to read, write and speak the English language. I declare that I am entitled to work in Australia as either a permanent resident or temporary resident with a visa that entitles me to work in Australia.

Office use onlyVisual Acuity

Both Right Left

Was eye test conducted with corrective lenses?

Yes No6/6/6/

Road Transport Authority | PO Box 582 Dickson ACT 2602 | Phone: 13 22 81

For full requirements on upgrading your licence please visit www.act.gov.au/accessCBR or phone 13 22 81.

Class/Condition Minimum age Minimum tenureLR or MR 18 years of age 12 months C class driving experience.

HR 19 years of age 24 months C class driving experience.HC 19 years of age 12 months MR or HR class driving experience.MC 20 years of age 12 months HR or HC class driving experience.‘O’ N/A Full Australian C or higher class licence for a for at least 1 year (or for periods totalling 1 year) in the last 3 years.‘M’ N/A Full Australian R or higher class licence.

‘H’, ‘W’, ‘D’ or ‘T’ N/A Full Australian C or higher class licence.

Upgrade of driver licence information

Working with Vulnerable People registration number Expiry datePublic Vehicle driver licence applicants only

Authorisation to Release Public Passenger Driver Licence and Accreditation Status

70,049 (10/2016)

Office use only

Accepted by Signature Date

Application type

Taxi Hire car (including restricted and motorcycle hire car) Public bus Rideshare

I am applying for the following Public Vehicle Driver Licence Class:

Personal details

Postal address

Residential address

Other namesSurname Given name

Date of birth Business hours contact number Mobile phone number

Driver licence number Driver Authority Number (if applicable)

E-mail address

Consent

Signature Date

I consent to the ACT Road Transport Authority:

1. Releasing information to Transport Booking Services regarding the status of my public passenger serviceaccreditation and/or my licence to operate a public passenger service and /or my driver’s licence or public vehicledriver authority.

2. Releasing information to third party insurers or individuals or their agents following a motor vehicle accident involvinga public passenger vehicle I operate.

3. Obtaining details on any matter from a Transport Booking Service and/or any other Government agency relating tothe operation of my public passenger service and/or driver’s licence or public vehicle driver authority.

4. Obtaining details of any matter, including details relating to a conviction, which may be deemed relevant to ascertain ifI am a suitable person to hold a public passenger service accreditation and/or a public passenger driver’s licence.

This form must be returned to the Licence Registration Unit at Road Transport Authority via:Email: lara@act.gov.au or Post - P.O Box 582 Dickson ACT 2602 or Fax - 02 6207 7120

Road Transport Authority | PO Box 582 Dickson ACT 2602 | Phone: 13 22 81

CONFIDENTIAL

The doctor may extend the examination where considered clinically appropriate, but must advise the applicant of any extra costs involved.Payment for the medical examination is the responsibility of the licence holder / applicant.

If this form is not returned by the due date, your Public Vehicle Licence will be suspended.

Commercial Driver’s Health Assessment10,004 (10/2017)

Applicants for an original ‘T’ (Taxi), ‘O’ (Public Bus), ‘H’ (Private Hire Car), ‘W’ (Restricted Hire Car), ‘M’ (Hire Car Motorcycle) or ‘D’ (Rideshare) public vehicle licence are required to undergo an initial medical examination by their General Practitioner (GP) and appropriate specialist prior to the grant of the public vehicle licence. Holders of a ‘T’, ‘H’, ‘W’, ‘M’ or ‘D’ public vehicle licence must thereafter undergo a 5 yearly examination by their GP until the age of 70, at which time a practical driving assessment must also be completed at the applicant’s cost. Accredited driving instructors and holders of an ‘O’ condition must also undergo an annual examination by a GP. Please note, certain medical conditions may alter the timeframes above.

If the completed Health Assessment is not returned by the due date, the public vehicle licence and public vehicle driver authority will be suspended until the assessment is received. Should you wish to apply for an internal review of this decision, applications for review should be addressed to:

• The Manager, Transport Licensing, PO Box 582, Dickson ACT 2602.

An application for internal review must be made within 28 days of receiving this form.

If you are not satisfied with the outcome of the internal review, you have the right to apply to the ACT Civil and Administrative Tribunal (ACAT) to review the decision of the internal review. An application to the ACAT regarding the subject of this form can only be made following an internal review.

Applications to the ACAT must be made within 28 days of the date of the decision of the internal review. Please note that an application fee may apply. Applications should be sent to:

• ACT Civil and Administrative Tribunal, Level 4, Moore St, Canberra ACT 2600.• Phone: (02) 6207 1740.

For further enquiries, in the first instance, phone Access Canberra on 13 22 81.

This application concerns: (Please place an X in the corresponding box)

Public Bus

Rideshare

Hire Car

Restricted Hire Car

Hire Car Motorcycle

Taxi

Heavy Vehicles over 8t GVM

Guidelines for completing this form

The Examining Doctor Must:

• Read Part A and sections of Part B of the booklet‘Assessing Fitness to Drive’;

• Review Section 1 with the applicant, and comment on anyabnormality;

• Complete Section 2 on page iv and the MedicalExaminer’s Certificate on page i;

• Return completed and signed copy of this form to theapplicant

The Applicant Must:

• Complete Section 1 on page ii and iii prior to the medicalexamination;

• Present the completed form to the examining doctor;

• If you wear spectacles, hearing aids etc. please bring themwith you to the examination;

• Supply the examining doctor with any relevantdocumentation.

Forward the completed and signed copy of this form to the relevant area:

Transport Licensing PO Box 582 DICKSON ACT 2602

Mail:

rusmedicals@act.gov.auE-mail:

Road Transport Authority | PO Box 582 Dickson ACT 2602 | Phone: 13 22 81

Accredited Driving Instructor

Heavy Vehicle Assessor

ADI Auditors PO Box 582 DICKSON ACT 2602

Mail: audit.bookings@act.gov.auE-mail:

Page i

Medical Opinion Action Required

I certify that I have examined the above mentioned patient in accordance with the National Medical Standards as set out in ‘Assessing Fitness to Drive’. In my opinion the person subject of this report:

Meets the relevant medical criteria for an unconditional licence. No further information required.

Examining doctor to obtain required information from specialist and attach report.

Requires appropriate specialist assessment and I have requested and obtained a report as attached.

Examining doctor to clearly note in the box provided:

1) Criteria not met and other relevant medical details

Does not meet the medical criteria for an unconditional or a conditional licence.

Examining doctor to clearly note in the box provided:

1) Criteria not met and other relevant medical details.

2) Proposed restrictions to licence (if appropriate).3) Suggestions for management and periodic

review interval (conditional licence).

Does not meet the medical criteria for an unconditional licence but may be suitable for a conditional licence based on opinion below and additional details attached as required.

Examining doctor to clearly note in the box provided,details regarding the medical condition as relevant to the driving task.

Requires practical driving test and is medically and psychologically fit to undertake a test.

Previously unlicensed or on a conditional licence but condition has now improved so as to meet criteria for a conditional or unconditional licence. No further information required.

Requires occupational therapist assessment and is medically and psychologically fit to undertake an occupational therapist assessment. Examining doctor to clearly note in the box provided,

details regarding the medical condition as relevant to the driving task.

Examining doctor to clearly note in the box provided, details regarding the medical condition as relevant to the driving task.

Requires an assessment by the Fitness to Drive Medical Clinic.

Licence holder / Application details

Medical opinion - medical practitioner to complete

SignatureName of examining doctor (please print or stamp) Date of examination

TelephoneAddress

Medical practitioner details

Residential address

Other names

Business hours contact number

Surname

Date of birth

Given name

Licence number

Please answer the following questions by ticking the correct box. If you are not sure leave it empty, the Doctor will ask you additional questions during the examination.

1. Are you being treated by a doctor for any illness or injury?

2. Are you receiving any medical treatment or taking any medication?

3. Have you ever had, or been told by a Doctor that you had any of the following?

3.1 High blood pressure

3.2 Heart Disease

3.3 Chest pain / Angina

3.4 Any condition requiring heart surgery

3.5 Palpitations / Irregular heartbeat

3.6 Abnormal shortness of breath

3.7 Head injury, spinal injury

3.8 Seizures, fits, convulsions or epilepsy

3.9 Blackouts or fainting

3.10 Stroke

3.11 Dizziness, vertigo, problems with balance

3.12 Double vision, difficulty seeing

3.13 Colour blindness

3.14 Kidney disease

3.15 Diabetes

3.16 Neck, back or limb disorders

3.17 Hearing loss or deafness or had an ear operation or use a hearing aid

3.18 Do you have difficulty hearing people on the telephone (including use of hearing aid if worn)?

3.19 Have you ever had, or been told by a doctor that you had a psychiatric illness, or nervous disorder?

3.20 Have you ever had any other serious injury, illness, operation, or been in hospital for any reason?

4.1 Have you ever had, or been told by a doctor that you had a sleep disorder, sleep apnoea, or narcolepsy?

4.2 Has anyone noticed that your breathing stops or is disrupted by episodes of choking during your sleep?

4.3 How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? (This refers to your usual way of life in recent times. Even if you haven’t done some of these things recently try to work out how they would have affected you).

Page ii

No Yes

Use the following scale to choose the most appropriate number for each situation. It is important that you put a number (0 to 3) in each of the 8 boxes.

0 = would never doze off

1 = slight chance of dozing

2 = moderate chance of dozing

3 = high chance of dozing

Sitting and reading

Watching TV

Section 1 - Applicant to complete

Sitting, inactive in a public place (e.g. a theatre or meeting)

As a passenger in a car for an hour without a break

Lying down to rest in the afternoon when circumstances permit

Sitting and talking to someone

Sitting quietly after a lunch without alcohol

In a car, while stopped for a few minutes in the traffic

SituationChance of dozing (0 - 3)

Applicant’s declaration (in presence of health professional)

5.2 How many drinks containing alcohol do you have on a typical day when you are drinking?

5.3 How often do you have six or more drinks on one occasion?

5.4 How often during the last year have you found that you were not able to stop drinking once you had started?

5.5 How often during the last year have you failed to do what was normally expected from you because of drinking?

5.6 How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

5.7 How often during the last year have you had a feeling of guilt or remorse after drinking?

5.8 How often during the last year have you been unable to remember what happened the night before because you had been drinking?

5.9 Have you or someone else been injured as a result of your drinking?

5.10 Has a relative or friend or a doctor or other health worker been concerned about your drinking or suggested you cut down?

6. Do you use illicit drugs? No Yes

7. Do you use any drugs or medications not prescribed for you by a Doctor? No Yes 8. Have you been in a vehicle crash since your last licence examination? No Yes

If Yes, please give details:

1 or 2 3 to 5 5 to 6 7 to 9 10 or more

5.1 How often do you have a drink containing alcohol?

Never

Monthly

Two to four times a month

Two to three times a week

Four or more times a week

Never Less than monthly Monthly Weekly Daily or almost daily

Never Less than monthly Monthly Weekly Daily or almost daily

Never Less than monthly Monthly Weekly Daily or almost daily

Never Less than monthly Monthly Weekly Daily or almost daily

Never Less than monthly Monthly Weekly Daily or almost daily

Never Less than monthly Monthly Weekly Daily or almost daily

No Yes, but not in the last year Yes, during the last year

No Yes, but not in the last year Yes, during the last year

Page iii

Privacy Statement: The information you provide on this form is being collected to assess your compliance with the required medical standards. The information may be used by the Road Transport Authority for the purpose of any of its statutory functions.The lawful authority for collecting this information is the Road Transport (Driver Licensing) Regulation 2000. The information may be disclosed to Commonwealth, Territory or State law enforcement agencies; transport authorities in those jurisdictions; and government agencies authorised by law. The information may also be disclosed to medical professionals and driving assessors only as is needed to assess your ability to drive safely.

releasing medical information to the Road Transport Authority or a medical practitioner nominated by the Road Transport Authority, in order to assess my medical eligibility for a commercial vehicle driver licence.

I, (Print name in full) certify that to the best of my knowledge

the above information supplied by me is true and correct; and I consent to Doctor

Signature Date

Page iv

10. EpilepsyDate of last attack / /

8. Neuropsychological Assessment(Where clinically indicated apply the Mini Mental StateQuestionnaire or General Health Questionnaire or equivalent).

Score

Relevant Clinical Findings

Note comments on any relevant findings detected in the questionnaire or examination, making reference to the requirements of the standards outlined in the ‘Assessing Fitness to Drive’ publication.

Is a driving assessment (A) or review (R) required by a medical specialist?

9. Diabetes

Insulin dependent

Tablets

Dietary

Does this affect his or her ability to drive? Yes No

Is a driving assessment or review requiredby a medical specialist? Yes No

Does this affect his or her ability to drive? Yes No

Note: Please refer to the table contained in ‘Assessing Fitness to Drive’ guidelines (Commercial Standards) on page 49 when assessing people with diabetes for a commercial licence.

Note: Please refer to the table contained in ‘Assessing Fitness to Drive’ guidelines (Commercial Standards) on page 57 whenassessing people with epilepsy for a commercial licence.

(A) Yes No

(R) Yes No

1. Cardiovascular System:

1.1 Blood pressure (repeat if necessary)

Systolic mm Hg mm Hg

Diastolic mm Hg mm Hg

1.2 Pulse Rate Regular Irregular

1.3 Heart Sounds Normal Abnormal

1.4 Peripheral pulses Normal Abnormal

2. Chest / Lungs: Normal Abnormal

3. Abdomen (liver): Normal Abnormal

4. Neurological / Locomotor:

4.1 Cervical Spine Rotation Normal Abnormal

4.2 Back Movement Normal Abnormal

4.3 Upper Limbs

(a) Appearance Normal Abnormal

(b) Joint movements Normal Abnormal

4.4 Lower Limbs

(a) Appearance Normal Abnormal

(b) Joint movements Normal Abnormal

4.5 Reflexes Normal Abnormal

4.6 Romberg’s sign* Normal Abnormal

*A pass requires the ability to maintain balance while standing withshoes off, feet together side by side, eyes closed and arms by sides,for thirty seconds.

5. Vision:

5.1 Visual Acuity

5.2 Visual Fields Normal Abnormal(Confrontation to each eye)

R L R L

6 / 6 / 6 / 6 /

Uncorrected Corrected

6. Hearing Normal Abnormal

7. Urinalysis

7.1 Protein Normal Abnormal

7.2 Glucose Normal Abnormal

Both

6 /

Both

6 /

Section 2 - Medical examiner to complete

Medical Examination of Commercial Vehicle Driver Licence

Please find enclosed your medical form to be completed by you and the doctor in order to maintain a valid commercial vehicle licence. Medical assessments are valid for six months from the date of issue.

The medical standards set out in ‘Assessing Fitness to Drive’ act as a guide for medical practitioners in providing expert advice when carrying out driver fitness checks on behalf of driver licensing authorities.

The standards (and medical form) were developed in conjunction with a range of medical organisations on behalf of the National Transport Commission (NTC) and Austroads and have been endorsed as the national standards for commercial vehicle drivers.

In accordance with the ACT’s commitment to national road safety initiatives, these standards apply to all drivers of public buses, taxis, rideshare cars, hire cars, restricted hire cars, riders of hire car motorcycles, accredited driving instructors, and heavy vehicles over 8 tonne GVM.

All medical practitioners in the ACT have been issued the medical standards. The assumed and preferred role of the examining doctor is to advise whether the criteria for driving a commercial vehicle are met. The ultimate decision as to whether a person applying for or retaining a commercial vehicle licence, is a matter for the Road Transport Authority.

Please follow the instructions on the medical form and arrange an appointment with your own doctor as required. If you pass the medical examination, the examining doctor will return the completed Commercial Driver’s Health Assessment to you, and it should be forwarded to Access Canberra Transport Licensing immediately. Failure to do so may result in your commercial licence being cancelled. Access Canberra Transport Licensing does not acknowledge the return of medical assessment reports. If there is a problem with the report or the report is not received by the due date, you will be contacted.

The completed Commercial Driver’s Health Assessment can be submitted to the relevant business unit listed on the front page.

Payment

The licence applicant is responsible for payment of the medical examination fee.

The Australian Taxation Office has advised that a tax deduction may be allowable for a medical expense that is sufficiently linked to a particular vocation. On this basis the cost of the examination may be claimed as a work related expense. For more information please contact the Australian Taxation Office.

SERVICE STANDARDS FOR RIDESHARE SERVICES

By submitting an application for accreditation the driver and licence holder agrees to implement procedures and systems for the operation of the rideshare service in accordance with the legislative requirements and acknowledges that those systems and procedures are subject to audit and inspection.

PART 1 Safety

1.1 The rideshare vehicle licensee of a rideshare service must:

(1) ensure that a rideshare vehicle is maintained, serviced and inspected so it remainsroadworthy at all times;

(2) ensure that a rideshare vehicle that does not pass a roadworthy inspection or hassafety equipment that is not working, and is deemed to be unsafe is not madeavailable for use as a rideshare vehicle;

(3) ensure (where relevant) there is an ability for drivers (other than the licensee) toinspect a vehicle before use for rideshare services and report vehicle or equipmentdefects and faults.

(4) provide the Authority full details of all security devices that they have installed orarranged to be installed in a rideshare vehicle, such as security cameras, GPStracking devices or other equipment used to monitor safety;

(5) for security devices under 1.1(4), ensure that there is the ability to capture datafrom the security devices and access that data as required for regulation purposes;

(6) where a third-party (other than an affiliated transport booking service (TBS) ) isused for the purposes of 1.1(5), provide the Authority with the third-partyprovider’s contact details;

(7) ensure that known defects with security devices and other equipment used tomonitor safety are repaired promptly.

1.2 The driver of a rideshare service must:

(1) drive in a safe manner at all times, and not negligently or wilfully move, drive orcause the vehicle to be moved or driven so that any person is subject to risk ofinjury;

(2) ensure that if a baby capsule or child restraint is provided, that it meets thestandards provided under the Road Transport (Safety and Traffic Management)Regulation 2000 and has no defects, such as a damaged harness belt, or significantcracks to the body of the device; and

(3) report to the rideshare vehicle licensee vehicle defects and faults that prevent useas a rideshare vehicle immediately after becoming aware of the defect or fault.

PART 2 Customers

2.1 The driver of a rideshare service must comply with procedures set by the relevant affiliated TBS for a hiring in relation to:

(1) customer inquiry, feedback and complaints;

(2) lost property procedures set by the TBS they are affiliated with.

2.3 The driver of a rideshare service must comply with the requirements of the Discrimination Act 1991.

PART 3 Certain Records Must Be Kept

3.1 The rideshare vehicle licensee of a rideshare service must maintain records, to be kept for a period of not less than 2 years, which are capable of being audited for:

(1) the period of time a vehicle is made available to a driver; and

(2) electrical, mechanical or structural repairs for maintaining the roadworthiness of arideshare vehicle – including the date, type and details of who conducted therepairs or maintenance.

3.2 Records to be maintained for the purposes of 3.1(1) above may be maintained by the affiliated TBS of the driver.

RIDESHARE DRIVER ACCREDITATION AND VEHICLE LICENCE APPLICATION FORM (Including Renewal)

Surname (Family Name): Mr Mrs Ms Miss Other

First Names (Given Names):

Company Name (if applicable):

ABN (if applicable):

Residential Address (PO Boxes not accepted):

Mailing Address (if different to above):

Email address:

Home Phone Number: Mobile Number:

Date of Birth: Drivers Licence No: State Issued:

Accreditation No: (if renewal)

Suitable Person Details Yes No

Have you been disqualified from managing a corporation under an Australian or foreign law.

Have you been convicted or found guilty of an offence against section 209(3) of the Corporations Act – public company giving financial benefits to a related party.

Have you been convicted or found guilty of an offence against part 5.8 of the Corporations Act – winding up of companies.

Have you been declared bankrupt in the last five (5) years.

Have you been disqualified under Chapter 8 of the Road Transport (Public Passenger Services) Regulation 2002 from holding or apply for accreditation.

Details of vehicle(s) to be used to provide the rideshare service

Registration Number(s):

Are you the nominated registered operator of the vehicle? Yes No If “Yes” ticked please provide details of Public Vehicle Insurer below.

Do you wish to obtain a one (1) year or a six (6) vehicle licence 1 yr ($100) 6 yrs ($450)

If “No” ticked - has a rideshare vehicle licence already been issued to the vehicle? Yes No

If “No” ticked then an ‘Rideshare Vehicle Licence’ Application Form must be completed by the registered owner of the vehicle and submitted with this Application.

Name of Public Vehicle Insurance Provider:

Commencement date of policy: Expiry date of policy:

IMPORTANT: A copy of the public passenger vehicle insurance policy must be submitted with this application. (NOTE: the public vehicle insurance policy should be in the name of the nominated registered owner of the vehicle).

List the Transport Booking Services you will, or intend to be, affiliated with:

RIDESHARE VEHICLE LICENCE APPLICATION (Including Renewal)

Section 164B & 164K of the Road Transport (Public Passenger Services) Regulation 2002

TO BE COMPLETED BY THE NOMINATED REGISTERED OPERATOR OF THE VEHICLE IF THE REGISTERED OPERATOR IS NOT GOING TO BE THE ACCREDITED DRIVER OF THE VEHICLE

OR THE ACCREDITED DRIVER IS NOT NOMINATED REGISTERED OPERATOR OF THE VEHICLE

Registration Number of Rideshare Vehicle

Business / Company Name vehicle is registered in (if applicable)

ABN/ACN (if applicable)

Surname

Given Name(s)

Business Address

Postal Address

Contact Telephone No

Email Address

Are you an

Australian Citizen a Permanent Resident or a Temporary Resident

Passport Number

Country Passport Issued

Accreditation Number (if applicable)

I consent to the ACT Road Transport Authority:

1. Releasing information to Transport Booking Services regarding the status of my rideshare vehiclelicence.

2. Releasing information to third party insurers or individuals or their agents following a motorvehicle accident involving the rideshare vehicle.

3. Obtaining details on any matter from a Transport Booking Service and/or any other Governmentagency relating to the operation of the use of my vehicle to be used as a rideshare vehicle.

Signature: _______________________________ Date: ___________________________