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City of Perth
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New Licence
Edit Licence
Licence Enquiry
Licence Fee Enquiry
Application Enquiry
New Payment
Edit Payment
Applications
New Application
Edit Application
Application Enquiry
Customer Service
New Customer Service Request
Edit non submitted Customer Request
Licensing
New Licence
Edit Licence
Licence Enquiry
Licence Fee Enquiry
General Enquiry
Application Enquiry
Payments
New Payment
Edit Payment
* Denotes that the field is mandatory.
Driver Nomination
This form is a legal document and can be used as evidence in Court
Nomination Details
Full name and address details of driver must be provided or this nomination will not be accepted
I (Title)
Please Select
Miss
Mr
Mrs
Ms
Mx
Other
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:
*
Please Select
Person in charge of
Driver of
Purchaser of
*
Vehicle Registration Number
*
*
Infringement Number(s)
*
*
On (Date of Infringement)
*
*
Date is invalid.
was (Title of driver)
Please Select
Miss
Mr
Mrs
Ms
Mx
Other
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
Evidence to support Nomination
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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