TRANSITIONAL ASSISTANCE PAYMENTS
MR158905/17
Application for Individual/Joint Holders of a Permanent Taxi Licence or Lease Holders as at 12 April 2016.
1. Licence / Lease Details
TAXI LICENCE NUMBER
DATE ISSUED
2. Licence / Lease Holder Details
ACCREDITATION No.
OWNER / LESSEE FULL NAME / COMPANY NAME
PHONE No.
ABN FOR BODY CORPORATE CLIENTS ONLY
POSTAL ADDRESS
DATE OF BIRTH
3. Joint Client Details (Please attach another page for additional client details)
FULL NAME / COMPANY NAME
ACCREDITATION No.
DATE OF BIRTH
DATE OF BIRTH
FULL NAME / COMPANY NAME
ACCREDITATION No.
FULL NAME / COMPANY NAME
ACCREDITATION No.
DATE OF BIRTH
DATE OF BIRTH
ACCREDITATION No.
FULL NAME / COMPANY NAME
4. Authorised Agent
Joint and Body Corporate clients must nominate one representative to act on behalf of the client who may be a member of the joint client. Evidence of identity must be supplied by the nominated person.
CONTACT No.
FULL NAME / COMPANY NAME
DATE OF BIRTH
5. Supporting Documents
All documents must be certified as a true copy of the original document by an Australian Legal Practitioner (solicitor or barrister) or a Justice of the Peace (must show registered number).
PLEASE COMPLETE ONE FORM PER TAXI PLATE.
You must provide certified copies of the following documents:
• Proof of ownership of eligible taxi licence/s or leases
• Evidence of identity documents for all owners / lessees, including one primary document.
For more information on Evidence of Identity requirements, go to
www.sa.gov.au/driverslicences
Acknowledgement and Declaration
Passenger Transport Act 1994.
• I/We declare that I was/we were the owner/lessee of the taxi plate nominated on this form and hereby certify that this application is to the best of my knowledge true and correct. I/we understand that this information is to be used for the purpose of administration of the
Passenger Transport Act 1994 and if it is false or misleading I/we may be guilty of an offence and I/we may be liable to repay the Industry Assistance Package payment.
• I/We will provide any further information or documentation as requested by the Department of Planning, Transport and Infrastructure to assist in the assessment of my application for industry assistance and am/are aware that this information is to be used for the administration of the
Passenger Transport Act 1994.
• I/We understand that my/our application cannot be processed unless I/we provide this information.
• I/We have attached to this application:
– evidence of ownership of the eligible taxi licence/s and leases; and
– evidence of the identity of each licence owner, lessee or authorised agent listed on the application.
• I/We authorise the Department of Planning, Transport and Infrastructure to address all correspondence relating to this application to the authorised agent listed in Section 4 overleaf.
• I/We acknowledge that only one lump sum payment will be made to the nominated account listed below – split payments will not be provided.
• I/We acknowledge that the Department of Planning, Transport and Infrastructure may place further information regarding the Industry Assistance Package on www.dpti.sa.gov.au/TaxiHireCarReview.
Nominated Bank Account Details as agreed by all parties signed below.
ACCOUNT HOLDER’S FULL NAME / COMPANY NAME
BSB
ACCOUNT No.
FINANCIAL INSTITUTION
SIGNATURE
DATE
/ /
I/We agree to the above declaration and nominated bank account details. All owners / lessees must sign below.
FULL NAME / COMPANY NAME
SIGNATURE
DATE
/ /
FULL NAME / COMPANY NAME
SIGNATURE
DATE
/ /
FULL NAME / COMPANY NAME
SIGNATURE
DATE
/ /
SIGNATURE
FULL NAME / COMPANY NAME
DATE
/ /
