Photo Kit

VicRoads, PO Box 2482, Kew 3101 Telephone: 13 11 71 TTY (for hearing impaired) : 1300 652 321 Website: vicroads.vic.gov.au
Overseas callers ph 613 9854 2666
88278
VRPIN00228 07.10
ABN 61 760 960 480
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Insert photo here
Please complete the relevant sections of this form and sign below in the presence of an Authorised Witness.
Please print clearly in ink using BLOCK letters.
If you are applying for a renewal or replacement, a fee may be required.
Please check vicroads.vic.gov.au for the amount payable.
Licence/Learner Permit No.
Witness Details
Name in Full
Home Address
Postcode
I,
Email Address (optional) Phone
Date of Birth M M Y Y Y Y D D
Signature Witness Signature
Date
Position/Title
M M Y Y Y Y D D
Photo Requirements
1 You need a current colour passport photo 45x35mm
in size printed on unglazed paper showing a full front view
of your head and shoulders on a white background. No
head gear, unless worn for religious purposes (veils are
not acceptable), nor sun/dark glasses should be worn.
2 Print your full name, date of birth and licence number on the
back of the photo.
3 Take this form and the passport photo to be witnessed. A
description of persons who can be witnesses is on the right.
4 The witness must:
read this form
see your evidence of identity
complete the witness details below
sign this form and the back of the photo.
Authorised Witnesses
An authorised witness includes any of the following people:
an employee of VicRoads
an accredited licence assessment provider or agent
a member of the police force
a consular or ambassadorial officer
a person authorised to witness and sign statutory
declarations
a person having one of the above equivalent occupations
in another state or country.
Applicant Details
Surname First Given Name Second Given Name
Phone (include all area codes)
or email address
* Mailing Address
Send your cheque to the postal address below or alternatively complete the following payment details.
Applicants Name in Full
certify that the above is a true photograph of
Evidence of Identity
The witness is satisfied as to the identity of the person either by sighting the current
licence or multiple evidence of identity. Evidence of residence does not apply to applicants
outside Victoria.
Please cross the appropriate circle
Current driver licence or permit sighted
Multiple evidence of identity sighted
Date of Birth M M Y Y Y Y D D
Postcode
* Your licence will be mailed to the current address
on your licence. If you require your licence to be sent
elsewhere, please specify the new address in the
Mailing Address box on the form.
Boat Vehicle
Signature of Cardholder
Credit Card Number
Total Amount $
Name of Cardholder
Date of Expiry M M Y Y Y Y
Payment Details Mastercard Visa
Applicants Signature (Sign in white area using black ink)
Providing false and/or misleading information or documents is a serious offence under the Road Safety Act 1986 and/or Marine Act 1988 and can result in you being
fined or imprisoned. Any authority or approval, given as a result of you providing such information/documents, may be reversed and have no effect.
By signing this form, I declare
that all information and/or
documents provided by me is
true and correct.
Yes No Do you want this new address recorded on your licence?
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