Queensland Residency Declaration

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Queensland Queensland Residency Declaration
Photo Identification Card Act 2008
• Government Transport Operations (Road Use Management) Act 1995 {TORUM)
This form may be used Ifyou are required to give evidence of your Queensland (Qld) resldentlal address and you are 1enulnely unable to provide
suitable evidence of residential address documents.
1 Personal details Daytime contact phone number
Family name (please print) I ofID832/ 491
I !,lli to VII z. MltciEl. 4 Verifying person's declaration
Given name/s • I declare that the person making this declaration ordinarily
I Zo~erl¾ resides with me at the residential address stated on this
declaration.
Residential address • I give permission for the authorising person to contact me for any
Ill) further Information considered necessa,y for the purpose of this
declaration and agree to give any further Information that the
j•
Postcode authorising person may ask for to verify any statement made by
me In this declaration.
Postal address (if same as residential. write •as above') I declare that. to the best of my knowledge, the information given
by the person making this declaration ls complete, true and
correct.
I
1----"'----"---''---------------·
....__ _ _ _ _ _ _ _ _ _ _ _ _Po.;_;st;;.;.co=de;;___ ___,1 • I declare that the Information I have provided in this declaration
Email address Is complete, true and correct In every detail.
I. ZOil~rR. VftZ, (!. J)(J -rltX)I(. . CO._,., • A I. • 1give permission for the authorising person to access my record
to confirm the information provided by me in this declaration.
Daytime contact phone number Date
_Q_..a..4....;..l-=-0_5_5-=3-=-J---'-1~~--J I...IC~.Llit-~UII ,..;;.;.~~~_;,;_,;. - - - - - , 1 1 6 . I 11. / 2023
••
.__I I
Town and country of birth

f,llll z. ,' i
r the TORUM and the Photo Identification Card Act
f'JBO ~u is-
t san o
to state give a document to an authorised person if you
2 Personal declaration knowitc lse or misleading information. Penalties apply.
Sip OIIIJlathepmeau oltllewdfyl-,perso11. PlhltyS111•111C.TMRcolledsthlshlfonaatioe undtrlfle p,uwisionsdlfle
• I declare that the information I have provided in this declaration TORUM and the Photo ldentlllc.ation Cant Ad lo --ae U. Queensland drMt
liunce, whlde rqistrltioll, AM ant and PhalD D Qld fllislm,. Tiil naa,
is complete, true and correct in every detail dlsdoselnfonnationabout,oclfdrlnrlcfflCetD ....maead fareipdrher
• I understand that failure to provide complete, true and correct lkenslns authorities and the Quemslalld 8Dllce Sena cr,is>. hllanaalion
information in this declaration may result in my declaration being about your AM card or Photo ID ant.., be disdosed ID. . . . . that
refused. Issue pn,of of qeOf idefttlllallioft unlsudlfleQPS. ............ whide
• I authorise the authorising person to make any enquiries reslstrattons maybedJsclosed to lllletmtewllklf llli,taatiu.. wetllm
lnsums. 1-,en. statutory• lnsoMnty fllllties. pers.-s ilMMd I n ~
considered necessary to verify the infonnation provided by me in acddents/lncldenls. whlde 111W parlieswllOMt ilMMd In
this declaration. or Intend to (OffllMQ(f lepl pn,cftClnss. llllinl~- llwtMll'CHlent
• I consent to the Department of Transport and Main Roads apncln. Your lnfonnation will not be llsclosed lo any odM!r lhkd party without
(IMR) taking. kffping and using my personal information and your consent. unlm requlrtd or authollstd by llw.
documents for the purposes associated with my driver licence,
industry authority, adult proof of age (APA) card and photo Office 1111 only
identification (Photo 10) card as required underTORUM and the Conftnutlon of Vlllfyln1 stat•11ts dleddlst
Photo Identification Card Act or otherwise authorised by law. On receipt of this completed form. the authorised person may confirm
Signature .:.Da~t....
e _ _ _ ___, the verifying person's stattments (lf required) by ttlephoning the
,~~~muJI 1~, /113,d verifying person.

Verifying person•s driver licence/APA c1rd/Photo 10 card
details confirmed In TRAILS/TICA
D
It ls an offence under T0RUM and the Photo Identification Card Act to
state anything or give a document to an authorised person If you know Verifying person•s residential 1ddress confirmed In TRAILS/ D
it contains false or misleading Information. Penalties apply. TICA
3 Verification of residential address Decision
The following declaration must be completed by a person who - Has this declaration been accepted?
- is at least t8 years of a,e YesO No 0
- is a current Qld driver licence. APA card or Photo 10 card holder
- resides at the same address as you. Comments
v.tfwllll,..........11
Family name (please prtn6
I 3/l&~i EtllVCfSCO
I- ---·-----------~
Authorising person's signature 01te
Given name/s ,~~~--,PL----'_,___.
I ?2if60
Office st1mp
Driver licence/APA card Photo 10 card number
$1
bsldenlill address

Queensland Residency Declaration

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Queensland Residency Declaration

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lfPrint For:] lfe!

Town and country of birth

,~~~muJI 1~, /113,d verifying person.

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