Application to become a Proprietor

Approved Vehicle Certifier Approved Inspection Station scheme

Personal Information Protection Statement

You are providing personal information to the Registrar of Motor Vehicles, who will manage that information in accordance with the Personal Information Protection Act 2004 and relevant provisions of the Vehicle and Traffic Act 1999. The personal information collected here will be used by the Registrar of Motor Vehicles for driver licensing and vehicle registration purposes, and related purposes under the Vehicle and Traffic Act 1999 and associated laws, including for national identity matching and verification purposes. Failure to provide this information may result in your application not being processed, or records not being properly maintained. The Registrar of Motor Vehicles may also use the information for related purposes, or disclose it to third parties in circumstances allowed for by law. You have the right to access your personal information by request to the Registrar of Motor Vehicles and you may be charged a fee for this service.

First Name

Last Name

Email Address

Date of birth

Phone number

Driver licence

Postal address:

Street address

City

State

Postcode

If already a Vehicle Examiner (VE) at an Approved Inspection Station (AIS), supply VE and AIS number.

VE number

AIS number

Previous AIS roles

Current Employment

Company name

Job title

Primary role

Business phone number

Business mobile number

Business address

Street address

City

State

Postcode

Declaration

I (write name)

confirm that the above information is correct and that if accepted as a Proprietor I will conduct the role of a Proprietor in accordance with the Vehicle Modification Certification Manual requirements relating to the Key Location of

Insert key location

Signature

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Date