Government of Western AustraliaDepartment of Transport

Driver and Vehicle Services

MDL 26

Application for Replacement/Certified Copy of Driver’s Licence

TO REGISTER YOUR INTENTION FOR ORGAN DONATION, PLEASE CALL MEDICARE AUSTRALIA ON FREECALL 1800 777 203. Licence Holders Details

SURNAME: ..........................................................................................

OTHER NAMES: ..................................................................................................................................................................

ADDRESS: ............................................................................................................................................................................

.................................................................................................................................... POSTCODE: ..........................

DATE OF BIRTH: / / LICENCE NUMBER:

Original Licence Lost Stolen (Complete declaration below) Destroyed

SIGNATURE: ................................................................................. DATE: .....................................

WITNESS: ........................................................... DRIVER & VEHICLE SERVICES CENTRE/ AGENT: ...................................

It is an offence to give false or misleading information. PENALTIES WILL BE ENFORCED UNDER THE OATHS, AFFIDAVITS AND STATUTORY DECLARATIONS ACT 2005.

Stolen licences only

STATUTORY DECLARATIONOaths, Affidavits and Statutory Declarations Act 2005

I ___________________________________________________________________________________________________________________________________

(Full Name)

of __________________________________________________________________________________________________________________________________

(Address)

do solemnly and sincerely declare that to the best of my knowledge my driver’s licence has been stolen and reported to the Western Australian Police Service.

Declared at _________________________________________________ this _______________ day of ______________________ year __________

Signature of Declarant: ______________________________________________________________________________

Police Incident Report Number: ____________________________________________________________________

Declared before authorised witness: ___________________________________________ _______________________________________ (See back of form for explanation) (Surname) (Other names)

___________________________________________ _______________________________________ (Qualification) (Signature)

A free replacement licence will be issued if you complete the Statutory Declaration below AND provide a Police Incident Report Number.

Proof of Identity CheckPRIMARY Birth Cert. Passport Immigration Doc. Citizenship Naturalisation Doc. Proof of Age Card Old Licence I.D. Document No. ___________________________SECONDARY(Specify) ..........................................................................................................................................................................

REPLACEMENT ISSUED: YES DATE:

SIGNATURE: DRIVER & VEHICLE SERVICES CENTRE/ AGENT:

Last updated: 14/10/2011

OFFICE USE ONLY

Academic (Post-Secondary Institution)

Accountant

Architect

Australian Consular Officer

Australian Diplomatic Officer

Bailiff

Bank Manager

Chartered Secretary

Chemist

Chiropractor

Company Auditor or Liquidator

Court Officer

Defence Force Officer

Dentist

Doctor

Engineer

Commonwealth Industrial Organisation Secretary.

Insurance Broker

Justice of the Peace

Lawyer

Local Government CEO or Deputy CEO

Local Government Councillor

Loss Adjuster

Marriage Celebrant

Member of Parliament

Minister of Religion

Nurse

Optometrist

Patent Attorney

Physiotherapist

Podiatrist

Police Officer

Post Office Manager

Psychologist

Public Notary

Public Servant (State or Commonwealth)

Real Estate Agent

Settlement Agent

Sheriff or Deputy Sheriff

Surveyor

Teacher

Tribunal Officer

Veterinary Surgeon

Any other authorised person under the Statutory Declarations Act 1959 of the Commonwealth

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

40.

41.

42.

43.

44.

AUTHORISED WITNESS

The declaration on the front of this form must be made before any of the following persons:

FOR MORE INFORMATIONMore information is available online at www.transport.wa.gov.au/dvs or by calling the Driver and Vehicle Services Call Centre on 13 11 56.

LODGING YOUR APPLICATION BY POSTIf you wish to lodge your application by post you must also supply the following documents:• Certified copies of primary and secondary proof of identification (information on acceptable proof of identity documents can be

located online at www.transport.wa.gov.au/dvs ) • Police incident report number - for stolen driver’s licence documents only• Payment - for lost, damaged and replacement driver’s licence documents only

Credit card Authorisation form* Required fields

CARDHOLDER NAME *

CARD NUMBER *

CREDIT CARD * Visa Mastercard

EXPIRATION DATE *

BILLING ADDRESS *

CITY * STATE/ PROVINCE * POSTAL CODE * COUNTRY *

PHONE NUMBER * EMAIL ADDRESS

I authorise the Department of Transport to charge my credit card in the amount of: $

PRINTED NAME * SIGNATURE * DATE *