Roads and Maritime Services

Customer Number Application

Private customer
To get a Roads and Maritime Services (Roads and Maritime) Customer number you must prove your Office Use
identity. A copy of the brochure 'How to prove who you are' is available from a service centre or
registry. You must attend in person to complete this transaction. Customer number allocated

If you cannot provide an acceptable proof of identity document that shows your signature you must
complete the witness to applicant's signature section on page 2.
Attachments

1 Customer details (use BLOCK LETTERS) 2 Do you hold or have you ever held a licence to drive or
Name ride in NSW, or a Roads and Maritime issued photo card
or conducted any business, such as registering a vehicle,
with Roads and Maritime that required the issue of a
customer number in the above name or in another name?

no
Residential address yes Give details below
Licence/customer number Class of licence

State Postcode Expiry date Registration plate number

Mailing address (if different from residential address)

day
/ month
/ year

Other name

State Postcode
What other business have you conducted?
Email address

3 Customer consent
Roads and Maritime is collecting your personal information in order
Mobile number (please provide a mobile phone number if you to create your Roads and Maritime customer number. We may
would like to receive communications from Roads and retain and use your personal information for driver licensing, motor
Maritime this way) vehicle, road transport and safety purposes.
Providing this information is voluntary but we may refuse your
application unless you do so in which case you may not be able to
transact business with us.
Date of birth We may disclose your personal information to other driver licensing
and vehicle registration agencies, to assess your application or

day
/ month
/ year
verify the information you provide, for inquiries about motor
accidents, to confirm compulsory third party (bodily injury)
insurance is current, to anyone proposing to acquire an interest in
Sex your vehicle and in respect of inquiries relating to stolen or
male
abandoned vehicles.
female Otherwise we will not disclose your personal information without
your consent unless authorised by law.
Pensioner number (if applicable) Your personal information will be held by Roads and Maritime at
20-44 Ennis Road, Milsons Point NSW 2061. You have the right to
access and correct the information if you believe that it is incorrect.
You declare that the information on this form is true and complete.

Signature

Date

day
/ month
/ year
Continued next page
Catalogue No. 45071265 Form No.1411 (07/2017) Page 1 of 2

UNCLASSIFIED
SENSITIVE: PERSONAL
4 Witness to applicant's signature Office use only
Required when you cannot provide an acceptable proof of Reason for establishment of customer
identity document that shows your signature.
If witnessed by a parent or guardian they must attend the
motor registry with you and show proof of their own identity.
Name of applicant (block letters) Proof of identity record
Stand-alone or primary proof

Signature of applicant
Passport / Visa -
Document number date of issue or Expiry Date

Witness declaration day

/ month
/ year
I certify that the applicant, whose name and signature
Secondary proof
appears on this form has signed in the signature box in my
presence.
My personal information is being collected for verification of
the applicant's signature. My witnessing of the applicant's Date of issue or expiry date
signature is voluntary. My personal information held by
Roads and Maritime may be disclosed inside and outside
NSW to verify the contents of this application. day
/ month
/ year

Name of witness (block letters)

Parent or Guardian Proof of Identity
Type of proof
Signature of witness

Verified by
Position of witness - Employer / school principal / bank CSR's name
manager / parent / guardian (cross out those not applicable)
Daytime contact phone
Date number of witness
CSR's signature

day
/ month
/ year

Business address of witness

(can be residential address of parent / guardian) CSR's staff number

State Postcode

UNCLASSIFIED
SENSITIVE: PERSONAL
Catalogue No. 45071265 Form No.1411 (07/2017) Page 2 of 2
Cut here and hand to customer
Office Use Only

Customer name Customer number