Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Gender *

Male

Female

Citizenship *

Please select which best describes your citizenship:

New Zealand Citizen

Australian Citizen

New Zealand Permanent Resident

Australian Permanent Resident

Other

Contact Phone (Mobile)

(###)

###

####

Do you hold a NZ drivers licence?

Yes

No

Are you currently registered with Work and Income New Zealand?

Yes

No

Are you willing to obtain a DL9 medical certificate (for driver licensing purpose)

Yes

No

Maths

Please rate yourself in the following area

1 (Need help)

2

3

4

5 (No problems

Reading

Please rate yourself in the following area

1 (Need help)

2

3

4

5 (No problems

Comprehension

Please rate yourself in the following area

1 (Need help)

2

3

4

5 (No problems

Do you require further literacy and/or numeracy help?

Yes

No

Upon the processing of this application you may be given an appointment/interview time at which you will need to bring with you, your full Birth Certificate or Passport and current New Zealand Drivers Licence. Please note that these must be original documents as we must view all originals before taking copies for our records. I declare that to the best of my knowledge all the information supplied on and with this application form, is true and complete, and I consent to the disclosure of personal information as described above. *

I agree to all the above