* Denotes that the field is mandatory.
This form is a legal document and can be used as evidence in Court
Full name and address details of driver must be provided or this nomination will not be accepted
I (Title)
First or given name *
Surname *
Of (insert your postal address) *
Suburb (of your postal address) *
Postcode *
Mobile Phone
Home phone number
E-Mail Address *
Hereby state that the person who was the: *
Vehicle Registration Number *
Infringement Number(s) *
On (Date of Infringement) *
was (Title of driver)
First or given name of driver *
Surname of driver *
Address of driver (Postal address of driver) *
Suburb (of driver's postal address) *
State (of driver's postal address) *
Postcode *
Their phone number
Car Hire or Car Sales companies must attach rental or sales agreements.
Describe Attachment eg. Sales receipt
If you have evidence to support your nomination, attach here
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