Road Transport Authority PO Box 582 Dickson ACT 2602 Telephone: 13 22 81 Tick appropriate box:

Original Community Nurse

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50,005 (01/2013)

Application for a Parking Permit

Renewal (Permit No. ...........................)

Change of vehicle details (Permit No. ................................)

Resident - Area Manager must complete relevant section prior to lodging form with the Road Transport Authority Medical Practitioner (Fees apply to Medical Practitioner parking permits) Member of Parliament

Central Business District (Unrestricted) ACT Hospitals & Non-Paying Areas (Restricted)

Outside Central Business District (Excludes City) Given Names

Surname Residential Address Telephone: Home Vehicle 1

Work Vehicle 2 Vehicle 3 Vehicle 4

Registration No. Type (i.e. Sedan)

NOTE: Resident, Community Nurse and Red Cross are only entitled to ONE vehicle per application. Area Manager to complete (only required for Resident Parking Permit) Name of Area Manager / CEO Tenancy commenced / / Signature of Area Manager / CEO Official Stamp

I, the undersigned, certify that the applicant named above is the registered tenant at the nominated address. Todays date / /

Name of Organisation

Declaration by Applicant (Resident, Community Nurse, Red Cross, Member of Parliament) I, the person named above, apply for the issue of a parking permit for attachment to the motor vehicle(s) described above and certify that the information on this application is true and correct. I understand that the parking permit may be revoked by the Road Transport Authority in the event of misuse. Signature of applicant Date / /

Privacy Statement: The information sought on this form is to process your application for a parking permit. The lawful authority for collecting this information is the Road Transport (Safety and Traffic Management) Regulation 2000. The information may be disclosed to Commonwealth, Territory or State law enforcement agencies; transport authorities in those jurisdictions, Government agencies authorised by law; the compulsory third party insurer; and individuals, their agents or insurers following a motor vehicle accident.

Declaration by Medical Practitioner (only required for Medical Practitioner Parking Permits) I, the person named above, certify that the motor vehicle(s) described above will, if issued a Medical Practitioners parking permit, be used by me for the purpose of rendering medical attention only. I declare that the information on this application is true and correct and that I will abide by any conditions or restrictions applying to the parking permit. ACT Medical Board Registration No. Date / /

Signature of Medical Practitioner

Payment Details
Amount Telephone $ Credit Card Number Expiry date

Mth Yr

Name on card

Signature of card holder

Customer Service Officer to complete Staff members initials Date