Application for authority to assign a taxi-cab licence - Victorian Taxi ...
Application for authority to assign a taxi-cab licence - Victorian Taxi ...
Application for authority to assign a taxi-cab licence - Victorian Taxi ...
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Vic<strong>to</strong>rian <strong>Taxi</strong> Direc<strong>to</strong>rate<br />
<strong>Application</strong> <strong>for</strong> Authority <strong>to</strong> Assign a <strong>Taxi</strong>-<strong>cab</strong> Licence – Assignor<br />
To be completed by Assignor:<br />
<strong>Taxi</strong>-<strong>cab</strong> Licence No.<br />
Assignor Designated <strong>Taxi</strong>-Cab<br />
Licence Trader ID No.<br />
(if appli<strong>cab</strong>le)<br />
Licence Holder<br />
Accreditation No.<br />
DOT6105_F176_10/12<br />
LHA–<br />
DETAILS OF APPLICANT (Assignor)<br />
Individual applicants:<br />
Surname/Family name First name/Given name<br />
Non-individual applicants:<br />
Name of Company, Partnership or Other Entity<br />
Responsible Person<br />
Address<br />
Postal address (if different from above)<br />
Telephone No.<br />
Home/Business Mobile<br />
Fax Email<br />
Postcode<br />
Postcode<br />
What is the name of the Network Service Provider with<br />
which the <strong>taxi</strong>-<strong>cab</strong> is currently affiliated? (if appli<strong>cab</strong>le)<br />
If a designated <strong>taxi</strong>-<strong>cab</strong> <strong>licence</strong> trader is involved with the<br />
<strong>assign</strong>ment of the <strong>licence</strong>, please tick the following box <strong>to</strong><br />
check that you have provided the following document:<br />
Authority <strong>to</strong> Act<br />
3<br />
DECLARATION<br />
I/We, the undersigned, being the <strong>assign</strong>or, declare that all<br />
answers <strong>to</strong> the questions in this <strong>for</strong>m are, <strong>to</strong> the best of my/our<br />
knowledge, true and correct.<br />
I/We have read and unders<strong>to</strong>od the Privacy Statement set out<br />
on the back page and I/we hereby consent <strong>to</strong> the Secretary<br />
<strong>to</strong> the Department of Transport (SDT) and the Department of<br />
Transport (DOT) collecting, s<strong>to</strong>ring and retaining all in<strong>for</strong>mation<br />
(including personal and sensitive in<strong>for</strong>mation) obtained from me/<br />
the <strong>assign</strong>or, any relevant persons in relation <strong>to</strong> the application,<br />
Vic<strong>to</strong>ria Police, VicRoads, the Department of Justice, the Sheriff’s<br />
Office, any other government department or agency, or other<br />
persons, and using, or disclosing that in<strong>for</strong>mation <strong>to</strong> third parties,<br />
or the contact person <strong>for</strong> this application, <strong>for</strong> the purposes of the<br />
Act or as otherwise authorised by law.<br />
Warning: It is an offence under the Act <strong>to</strong> provide false or<br />
misleading in<strong>for</strong>mation in this <strong>for</strong>m.<br />
Applicant’s signa<strong>to</strong>ry or signa<strong>to</strong>ries<br />
1. Name of signa<strong>to</strong>ry<br />
Role of signa<strong>to</strong>ry<br />
(see page 2)<br />
Signature Date<br />
2. Name of signa<strong>to</strong>ry<br />
Role of signa<strong>to</strong>ry<br />
(see page 2)<br />
/ /<br />
Signature Date<br />
3. Name of signa<strong>to</strong>ry<br />
Role of signa<strong>to</strong>ry<br />
(see page 2)<br />
/ /<br />
Signature Date<br />
Attach a separate sheet with further names, capacities,<br />
signatures and dates if necessary.<br />
Department of Transport<br />
Vic<strong>to</strong>rian <strong>Taxi</strong> Direc<strong>to</strong>rate, Level 23, 80 Collins Street, Melbourne VIC 3000 GPO Box 2797, Melbourne VIC 3001 Phone: 1800 638 802 (<strong>to</strong>ll-free) www.<strong>taxi</strong>.vic.gov.au<br />
Authorised by the Vic<strong>to</strong>rian Government, 80 Collins Street Melbourne 3000.<br />
Oc<strong>to</strong>ber 2012<br />
/ /