Taxi Industry Assistance Application Form

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

EMAIL

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

EMAIL

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

• I/We consent to the use of my/our personal information provided on this application or otherwise held by the Department of Planning, Transport and Infrastructure for the purpose of administering the

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

/ /

 

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