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Signature Date

/ /

Identity, Proof of Age and Residency sighted Staff initials

Indicate overleaf with a tick which documents were sighted.

Customer Service Ofcer to complete

The Privacy Act 1988 prevents the ACT Government from using your information and retained images for any

unauthorised purpose and require it to implement safeguards to protect the information and retained imagesfrom unauthorised access. Retained images may be used by the Department to assist in addressing identity

fraud. Images may be disclosed to law enforcement and court agencies as required, or under regulations or

another law.

The information you are providing on this form is to assess your application for an ACTION Gold Card. If you

knowingly provide false information on this application you may be prosecuted. The lawful authority forcollecting the information is the Road Transport (Public Passenger Services) Act 2001. Data from the form will

be entered on to a database maintained by the Department of Territory and Municipal Services. Information

from the database may be disclosed to transport inspectors and law enforcement agencies in connection with

the administration of the ACTION Gold Card Scheme.

To obtain an ACTION Gold Card an applicant must:

Provide proof of identity

Provide proof of age

Provide proof of ACT residency

For details on what can be used for identication purposes refer overleaf.

Postcode

Date of birth ACT Licence Number

Female

Address

First given name Second given name

Surname

Application for ACTION Gold Card

AUSTRALIAN CAPITAL TERRITORY GOVERNMENTRoad Transport AuthorityPO Box 582Dickson ACT 2602Telephone: 13 22 81

30,010 (05/2008)

This application is in respect of: Original Replacement Change of details

Male

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Tick the proof of identity and residency box for the types of proof that have been sighted.

Primary Proof of Identity: (documents which will be accepted)

A Photographic Driver Licence issued in Australia (current or expired up to 2 years).

Australian Birth Certicate (not a Commemorative Certicate and not an extract).If the certicate is not in the name currently used appropriate linking documentation will be required.

Australian Passport (expired up to 2 years).

Overseas Passport (expired by up to 2 years if accompanied by current Australian Visa).

Australian Citizenship Certicate or Naturalisation Certicate.

Department of Immigration & Citizenship travel document (valid up to 5 years after issue).

Department of Immigration & Citizenship Certicate of Evidence of Resident Status.

Portrait and Signature stored on Road User Services database.

Australian Defence Force Photo-identity card, excluding civilians.

Police Ofcer Photo-identity card (from ACT only).

Australian Proof of Age Card (includes NSW Photo Card) with appropriate security features, showing date of issue byan Authority, that is current or expired up to 2 years.

Secondary Proof of Identity: (documents which will be accepted)

Current Medicare card.

Current credit card or account card, with signature and embossed name from a Bank, Building Society or Credit Union.

Current Student Identity Document (with photo and / or signature) issued by Educational Institution.

Current Centrelink or Department of Veterans Affairs Concession Card.

Australian issued Security Guard / Crowd Controller Licence (with photo).

Australian issued Firearm Licence (with photo).

Current Consular photograph identity card issued by Department of Foreign Affairs.

Current State or Federal Government employee photo identity card.

Proof of Residency: (if not already established by Primary or Secondary Proof of Identity)

Provided the applicants residential address is listed on the document the following are acceptable:

Contract of Purchase, Current Lease or Rental Document for relevant premises (a receipt only is not acceptable).

Vehicle Registration Certicate (current).

Driver Licence or Vehicle Registration Renewal Notice for coming period.

Council Rates Notice (current).

Land Tax Valuation Notice (current).Australian Taxation Ofce Assessment (last or current nancial year).

Utility Accounts relating to the street address (Electricity, Gas, Landline Telephone or Water) paid within the last 3 months.

To make an application for an ACTION Gold Card all applicants must provide:

1. At least one form of Primary Proof (photocopies not accepted);

2. At least one form of Secondary Proof (photocopies not accepted);

3. One form of proof of Residency in the ACT (photocopies not accepted).

Customer Service Ofcer to complete