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"'Qvtcroads .\SN61700 480

Certificate of approved operations
Conditions of use for a heavy vehicle. Licence no,
Please oomplete the \\tite sections ot this form and sign below. Please print clearly in ink using
BLOCK leners. This certificate sets out the cond1110ns under which the vehicle O'klst be a"t'l'efl P.eglstratlon number
00 a higt'rllay.
Oatc<lf issue
This certificate must be carried In the vehicle at all times.

Registered operator's details

&lmame Oate of birth
First grl\1n name Secoll(l given name Thircl irntial fit tmJ1

Q:mpany name ar<I ACNIARSN (if 8iJPl«;8We)

Resklentlal for oompafl,? address

PostOOde

Poscal acldress (if different from rosidentjal O f COfl1l)8fff atklress)

Poslooel8

rv'lob!!e P,one no, for other ;t not 81)1]1,v:abliJ) Emall

Vehicle details
Make Model Body1)11e Com!r
\/IN (Chilssis or frame number i f no VIN)

Engine no. Engine type

Use of this 1Jehicle is restrlcced to actwlties assoaated with the category cd use nominated by Vic:Floads below, Use of the \'Ehlcle must also be in aocordance with the concltions
of use contained wltlllll this oertlflca1e. These oonclltloo.s ol use do not aftect, Hmlt or remo1,1e the vetilcle opera1or's obllgatloo 10 comply w1tfl other legcslatlw recptemeots or ruleS
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\\flen using a vehicle on a Road Rood Related Al'Ba.

Your signature
Personal lnformaoon VicP.oads ool1ects from you may be used by \ltcl\:lads. as permitted by the Road Sa+'etyAct 1986 and the Maline Safety Act 2010. VlcRoads may disclose
l)(!fSCf'lal information ij ooirects from you to variOOs organiSations and persons as permitted uy 1;:m, partiQJfatly by tile Road 58.'ety Act 1986. Tlis i ludes discloSing the informa'!ion
10 C()(ltracl()(S and 8!)ents 01 ViCRoods. raw enretcement 898f'lCies, olhe1 100.d and 1ramc autl'()ffties, Austr"OadS, Ille lfaJ'lS()(lrt Accident Commiss . vehicle manutactt.t8f'S {I« safely
roca!ls}. road safety researcfleffi, cou11.S anCI omer «ganisaUoos or poc,)te au1hetiSOO to use the personal inlo,matic,t
You are t8(Jjrecl to provicte this personal illf<:tmatiOn. Fa.re to provide the mo1mati0tl may resu11 in lhis 101m not being orooessect. Of reoords not being l)"()J)e11y maintained.
tOr' furttier infoonalion abOul our use <:J \'Oll' PtlfSOnal lnJormatbl al'Kl yaur 11ght ot access 10 ii. soo ViCAoaCls bu>chure Protec:rifl{J }'OUr' priv.acyOI' oootact VicRoadS on 13 11 71.

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Providing false and/or misleading infonnation or documents is a serious offenoe under the Road Safety Act 198fJ and/or Marine Safety Act 2010 and can result in
you being fined lmptlsonoo. A1ly authority or approval, given as a result 01 you ptoviding such intormaUonJdocumc,ns, may be reversed a1ld have no enoct
By signing this form, I declare that the information in this to,m and related supl)()rting documents is true, correct and complele, and I mderstand the privacy statement.

s;;ina!ure of app!icanl Signa.tuie of ault101ised ollioor

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Date

User Cl

OFRCE USE ONLY l'wpose fof whioh use o f vehicle is approved (lick appropriate 001():
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1, Govemment/local councllemergency ser\'ices 6 Utilities (electricity/gas/water/waste}
2. Prrnary proclJcer 7 Heahh care O'losp!ta:vaged carelrehab1tltatloo)
3. Cooslruction/malntroance/semce 8. Education or training faculty
4. Manufactlf'ing/pf'OCIUCllon 9. En1etta!nroont1recreat1onal 2
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5. TourisnvacrommOdation

__________.....,
10. Other (spo;:lfy)
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Po : \f,;f<JaOs GPO 8())( 1644, Meu,ow,e. v;c,o,ia, 3001 Call: 13 11 71 (TTY 13 36 77, Sileai< ar<J Li en 1300 555 727) Web: vil)'OOOS v .!JtW•u