This is an HTML version of an attachment to the Freedom of Information request 'A record of holding a Queensland Drivers license'.

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Release of Information Application
Adult Proof of Age Card Act 2008; Tow Truck Act 1973; Transport Operations (Marine Safety) Act
1994; Transport Operations (Passenger Transport) Act 1994; Transport Operations (Road Use
Management) Act 1995; Transport Planning and Coordination Act 1994
Please use this form if you are applying for the release of information or 2 Applicant’s details
documents collected by the Department of Transport and Main Roads
Family name (please print)
(the department). Fees may apply for some applications. Please refer to
section 5 and to for applicable fees.
Applying for driver licence, industry authority, marine licence
Given name/s
indicator or adult proof of age (APA) card information
You may apply for information about your driver licence, APA card,
industry authority or marine licence indicator, for example, licence details
Residential address
and history. Your application for the release of industry authority or
marine licence information may not be considered at the time of lodgement.
If your application is approved, the information will be sent to your
mailing or email address. Information about your driver licence including
Postal address (if same as residential, write ‘as above’)
the type and class of licence you hold, and whether your licence is valid
(not expired, suspended or cancelled) is also available online at
Applying for your traffic history
Email address
You may apply for details of your traffic history relating to contraventions
for which you have been dealt with under the relevant Act, including the
recording of demerit points.
Daytime contact phone number
You may also apply for your traffic history online at
(must be an Australian number)
Date of birth
/             /
Applying for your marine licence information
You may apply for details of your marine licence or your marine history 3 Can you show your Qld driver licence, industry
relating to contraventions for which you have been dealt with under the
authority, marine licence indicator or APA card?
relevant Act.
Licence number/CRN
Applying for another person’s information
Go to section 4
If you are applying for information from another person’s record, you
must have the written consent of that person. Your application will take
You are required to show three EOI documents (refer
longer as the person whose information you are applying for must be
to EOI Requirements for Individuals (form F4362))
contacted by the department to confirm the consent given. This application
Please provide details of your documents.
will be refused if the person whose information you are applying for
Category A (please print)
cannot be contacted during business hours.
Document type
Document number
(e.g. Qld BDM issued Birth
Applying for a copy of a document
(e.g. X0100011)
Please use form F4013 Application for Copy of Document Release Request.
Evidence of Identity (EOI) Requirements
Category B (please print)
You must give evidence of your identity. If you are applying in person,
Expiry date
Document type (e.g. Medicare card)
you may do so by showing your Queensland driver licence, industry
(if applicable)
authority, marine licence indicator (conditions apply) or APA card. All
/           /
cards must be current or expired by less than two years.
Category A or B (please print)
If you are unable to show one of the above you will need to present
Document number or expiry date
three other acceptable EOI documents. All documents must be originals.
Document type
(do not give credit/debit card number)
If you are applying by mail (interstate, overseas and remote applicants
only) certified copies of EOI documents are acceptable. Refer to
4 Have you changed your name?
For a full list of acceptable EOI, please refer to the Evidence of Identity
Requirements for Individuals (form F4362) or visit
You are required to show a change of name document.
Please provide details of your document.
Change of name (please print)
1 Are you applying for your own information or
Document type
Document number Registration year
(e.g. Qld BDM issued (e.g. 001000)
(e.g. 2010)
Marriage Certificate)
Please fill in sections 2 to 5 and section 8.
Please fill in all sections of the form.
Page 1 of 2
TRB Forms Area
Form F2121 CFD   V01 Dec 2016

5 What information or documents are you applying for? 8 Applicant’s declaration
(visit for applicable fees)
I declare that I have read all the answers I have given to the questions in
(a) Driver licence
this application and that the answers are complete, true and correct in every
detail. I understand that I may be prosecuted for giving or stating any false
Driver licence details
Driver licence history
or misleading information or documents.
(fees apply)
(fees apply)
I consent to the department taking, keeping and using my personal information
Traffic history (fees apply)
or documents for the purposes associated with my application as required
under the relevant transport Acts and the Adult Proof of Age Card Act or
(b) APA card
otherwise authorised by law.
APA card details
I consent to the department verifying my EOI documents or information
provided by me with the issuing authority or their agencies.
(c) Marine licence
Applicant’s signature
Marine licence details
Marine history
/         /
(d) Industry authority
It is an offence under the relevant Transport Act or the Adult Proof of Age
Current industry authority details
Card Act to state anything or give a document to an authorised person if
Industry authority history
you know it contains false or misleading information. Penalties apply.
Privacy Statement: The department provides this form under the provisions of the Acts
Which category?
nominated on this form so that you may apply for a copy of your own information or documents
Dangerous goods driver
Driver Authorisation
or another person’s information or documents that are held by the department. The information,
documents and digital photo collected for the purpose of this application may be accessible by
Driver trainer
Escort vehicle driver
authorised departmental persons and some of this information may be disclosed to the Queensland
Police Service as allowed under the relevant transport Acts or otherwise authorised under the
Pilot vehicle driver
Rider trainer
Police Powers and Responsibilities Act 2000. The department will not disclose your information,
documents, digitised signature or digital photo to any other third parties without your consent
Tow truck assistant
Tow truck driver
unless required or authorised by law.
Traffic controller
Office use only
(e) Other information
Applicant’s details confirmed in TRAILS/TICA
Address history (fees apply)
Name history
Applicant’s EOI confirmed
(f) Is this information or document required for a specific
1:1 match performed
Licence, industry authority, marine licence, APA card holder
has been contacted and their statements made on this form
Period from
have been verified
/           /
/           /
Note: Go to section 8 if you are applying for your own information or
If you are applying for another person’s information, sections 6 and
Application approved
7 must be completed to provide their details and confirm their consent.
Application not approved
6 Details of the person whose information or documents
you are applying for
Family name (please print)
Authorising person’s signature
Given name/s
/         /
Residential address
Office stamp
Qld driver licence number
Application filed Document/File ID
Daytime Australian contact phone number Date of birth
Filing person’s name
/             /
Town and country of birth
/         /
7 Driver licence, industry authority, marine licence, APA
card holder’s authorisation
I authorise the department to release information or documents relating
to my Qld driver licence, industry authority, marine licence or APA
card to the person described in section 1 Applicant’s details.
I give permission for the authorising person to contact me to verify any
statement made by me in this application.
I agree to give any further information that the authorising person may
ask for.
Card holder’s signature
/         /
Page 2 of 2
TRB Forms Area
Form F2121 CFD   V01 Dec 2016