NSW Photo Card Application

Important Customer Information

If none of your POI documents show a residential address or you cannot provide acceptable proof of address, the Reference
statement at item 8 must be completed.
If you do not provide a POI document that has your signature or cannot leave your mark or signature on this form, the Witness to
applicant's signature at item 9 must be completed.
If you hold a NSW Photo Card and you are getting a replacement or being issued a new one because the old one has expired, you
must hand in the existing card.
If you hold a NSW Driver Licence or Proof of Age (POA) Card and you want a NSW Photo Card, you must hand in the Driver
Licence or POA Card. A refund may be applicable on the remaining portion of your Driver Licence. There is no refund on the POA
Card.
You must hand in your NSW Photo Card if you want a NSW Driver Licence. There is no refund on the NSW Photo Card.
If your current Photo Card is lost, stolen, damaged or destroyed, you
must notify RMS in person at any registry as soon as practicable.
You must notify RMS about any change of name or address within 14
days after the change.
1 Personal details
Surname
Given names
NSW Residential address
Mailing address (if different from residential address)
NSW Licence/Customer number (if available)
Sex: male
Catalogue No. 45071151 Form No. 1359 (09/2012) ABN 76 236 371 088 Page 1 of 3
Date of birth
female
To get a NSW Photo Card you must provide Proof of Identity (POI) documents. The brochure 'How to Prove Who You Are' is
available from any registry. A list of suitable documents is also available on Roads and Maritime Services (RMS) website at www.
rms.nsw.gov.au.
Postcode
2 Do you have a current:
No
Yes
You must be at least 16 years old and live in NSW to be issued a NSW Photo Card.
Email address
Please provide your email address if you would like to
register for an online service account, go to myRTA.com for
more information.
Office
Use Only
Mobile number
Please provide a mobile number if you would like to receive
communication from RMS this way
Customer number Attachments
Postcode
Day Month
/
Year
/
NSW Seniors Card
a current intermediate pension or an assessment at 50
or more impairment points
NSW Pensioner Concession Card (PCC)
Centrelink Confirmation of Concession Card Entitlement
form stamped PCC
Centrelink letter confirming Carer Allowance
Department of Veteran's Affairs (DVA) Gold Card
endorsed 'TPI' or 'EDA' or 'War Widow' or 'War Widower'
DVA letter or statement certifying a disability pension of
70% or more
Now go to 3
RMS requests your consent to assess your eligibility for a
concession. This consent will be used for the sole purpose of
authorising the Department of Human Services - Centrelink or
Family and Community Services (FACS) to provide information to
Roads and Maritime Services (RMS) to assess your eligibility in
relation to concessions or services provided by RMS.
authorise the Department of Human Services - Centrelink or FACS
to confirm with RMS the current status of my Commonwealth
Benefit or NSW Seniors Card and other details as they pertain to
my concessional entitlement. This involves electronically matching
details I have provided to RMS with the Department of Human
Services - Centrelink, or Department of Veterans' Affairs (DVA)
records to confirm whether or not I am currently receiving a
Department of Human Services - Centrelink or DVA benefit.
I understand that this consent, once signed, is effective only for the
period I am a customer of RMS. I also understand that this consent,
which is ongoing, can be revoked any time by giving notice to RMS.
I understand that if I withdraw my consent, I may not be eligible for
the concessions provided by RMS.
A brochure is available from the Department of Human Services -
Centrelink that provides more details about the Centrelink
Confirmation eServices or on the department's website at www.
humanservices.gov.au
Day Month
/
Year
Date
/
I,
(customer name)
Now go to 3
Signature
9 Witness to applicant's signature
Required when you cannot:
Provide an acceptable proof of identity document with
your signature or,
Leave your mark on this application or,
Sign this application.
If witnessed by a parent, guardian or carer they must attend
the registry with you and show proof of their own identity.
Name of applicant (please print)
Signature/mark of applicant
Witness declaration
Reason why applicant cannot sign this form
Page 2 of 3
I certify that the applicant whose name and signature/
mark appear above has signed/marked in my presence.
I certify that the applicant whose name appears above
is unable to sign or mark this application for the
following reason.
Catalogue No. 45071151 Form No. 1359 (09/2012) ABN 76 236 371 088
Witness full name (please print)
(continued next column)
I understand that my personal information is being collected for
verification of the applicant's signature, mark or reason for not
signing the application. I am acting as a witness voluntarily. RMS
may disclose my personal information inside and outside NSW to
verify the contents of this application.
7 Privacy statement and declaration
Please read carefully before you sign.
If you do not tell the truth you can be fined.
RMS is collecting your personal information for your NSW Photo
Card application and may retain and use it for driver licensing,
motor vehicle and road transport or safety purposes.
RMS is entitled to obtain your personal information under the Photo
Card Act 2005 and may refuse your application if you do not
provide it.
RMS may disclose your personal information to assess your
application or verify the information you provide.
Otherwise RMS will not disclose your personal information without
your consent unless authorised by law.
Your personal information will be held by RMS at 101 Miller Street,
North Sydney NSW 2060 and you can contact RMS to request to
access or correct it.
You declare that the information on this form is true and complete.
Under the Photo Card Act 2005 it is an offence to obtain or apply for
a NSW Photo Card by false statement, misrepresentation or other
dishonest means.
You cannot have a NSW Photo Card and NSW Driver Licence at
the same time and you must surrender one before being issued
with the other. If you are surrendering a NSW Photo Card in order
to apply for a NSW Driver Licence, RMS may require medical
evidence of your fitness to drive.
Signature
Date
Day Month
/
Year
/
Required when you cannot provide proof of residential
address.
To be completed by a person who has known you for at
least 12 months and holds a current NSW unrestricted
Driver Licence. RMS may contact the referee to verify
information in this application.
Referee's full name (please print)
Referee's daytime contact
telephone no.
Please note: If you do not tell the truth in your reference
statement, both you and the applicant can be fined.
I declare that I have known the applicant for at least 12 months and
that to the best of my knowledge, the personal details given in item
1 are correct.
I understand that my personal information is being collected for
verification of the applicant's personal details. My supply of a
referee's statement is voluntary. RMS may disclose my personal
information inside and outside NSW to verify the contents of this
application.
**Please read important privacy information at item 10.
Signature of referee
8 Reference
Referee's Driver Licence No.
Day Month
/
Year
Date
/
3
a NSW Photo Card Now go to 4
I would like:
a replacement NSW Photo Card Now go to 5
4 Do you hold or have you ever held a licence to drive or
ride in NSW or a NSW Photo Card /Proof of Age Card in
the above name or another name?
No Now go to 7
Yes Give details below
NSW Licence / Customer number,
Photo Card / POA card number
Other name (if applicable)
Expiry date
Now go to 6
5
6 Surrender Driver Licence or POA card
If the card has been lost, stolen, damaged or destroyed you
will be required to sign a lost, stolen, damaged or destroyed
declaration.
Driver Licence
What is the reason for your application for a
replacement NSW photo card?
Lost
Stolen
Damaged/Destroyed
Poor card quality
Not received
Change of appearance
Personal details
have changed
POA card
Replacement NSW photo card?
(tick applicable box)
Stand-alone or primary proof Document number Passport/Visa date of issue or E/D
Secondary proof POI for parent, guardian or carer Proof of residential address
No stored image or
not requested
Matched Mismatched Faulty Failed to arrive on time
Verified by:
Name Signature
CSO number or agency name
Type of proof
Photo comparison
Office Use Proof of identity record
Card details (tick applicable box)
First issue of
Photo Card
Reissue/replacement
Photo Card
NSW Photo Card
handed in or declared
lost, stolen, damaged
or destroyed
NSW Driver Licence
handed in or declared
lost, stolen, damaged
or destroyed
NSW POA Card
handed in or declared
lost, stolen, damaged
or destroyed
Day Month
/
Year
Date
/
Page 3 of 3 Catalogue No. 45071151 Form No. 1359 (09/2012) ABN 76 236 371 088
Organ donation information

From November 2012 Roads and Maritime Services will
stop collecting and recording organ donor preferences.

NSW residents now need to register their organ and
tissue donation decision on the Australian Organ
Donor Register. You can register at donatelife.gov.
au/decide, visit your local Medicare Customer
Service Centre or call 1800 777 203.
For more information visit donatelife.gov.au
10 Important privacy information (please read)
Personal information, including any image, is collected and
held by Roads and Maritime Services (RMS), 101 Miller
Street, North Sydney NSW 2060. You have a right to
access or correct your personal information in accordance
with the provisions of the relevant privacy legislation.
Witness daytime contact
telephone number
Witness address (home or work)
**Please read important privacy information at item 10.
Position of witness (tick applicable)
Signature of witness
Day Month
/
Year
Date
/
(continued from previous column)
Postcode
Witness Driver Licence
number (if applicable)
Employer
Carer
School Principal
Bank manager
Parent
Guardian