Driver Nomination Form

I

Full Name

Please enter the full name of the vehicle owner

of

Auto-Complete

address and postcode

Phone Number

Email Address

Please enter your email so we can get in touch.

Driver's Licence Number

12 characters left

State issued

Date of Birth

Company Name

(N.B. If a company owned vehicle, state your position in the company and registered office of the company below)

Position in Company:

Registered Office:

Expiation number

The number on the top of your parking fine notice

Vehicle registration

10 characters left

Nomination type

Option A- At the time of the alleged offnce, the vehicle was sold, hired, or leased

Option B - I was the owner of the abovenamed vehicle but was not the driver

Option A - At the time of the Alleged offence , the vehicle had been sold hired or leased

At the time of the alleged offence, the vehicle was

Sold

Hired/Leased

Sold on

Hired/leased from

Hired/leased to

To

Full name or company name

Address

Date of birth

Driver's Licence number

State of issue

WARNING: Under section 174A (13) of the Road Traffic Act 1961, there is a maximum penalty of $25,000 or four (4) years imprisonment for making a statement that is false or misleading in a material particular, when making a nomination. You may be asked to make a statutory declaration to verify any information in this nomination.

I hereby state that this nomination is true and correct.

Print your full name here

signature

date

I was the owner of the above named vehicle but was not the driver. To the best of my knowledge and belief, at the time of the alleged offence, the driver was:

(FULL NAME or COMPANY NAME)

Of

(ADDRESS AND POSTCODE)