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New Customer Application (Individual)

Photo Identification Card Act 2008; Tow Truck Act 1973; Transport Operations (Marine Safety)
Act 1994; Transport Operations (Passenger Transport) Act 1994; Transport Operations (RoadUse Management) Act 1995; Transport Planning and Coordination Act 1994
This form is to be completed and signed when:•or•applying for a Queensland (Qld) Customer Reference Number (CRN)
you require a CRN for the issue of an Agency Card (for example Blue Card, Disability Worker Screening Clearance Card,
High Risk Work Licence).

Original Evidence of Identity (EOI) must be provided at the time of lodgement. To find out what to bring, go to
www.qld.gov.au/EvidenceOfIdentity
Note: If you previously held a Qld driver licence, Industry Authority, Marine Licence Indicator, Adult Proof of Age (APA) Card, Photo ID Card or
have a CRN, you do not need to complete this form.

1. Applicant’s details
Family name (please print)

Date of birth/

Given name/sTown, state and country of birth/

Residential address
Postcode
Postal address (if same as residential, write ‘as above’)
Postcode
Mobile phone number

Email address

Would you like to get e-notices and e-reminders?
YesNo

2. Evidence of Identity documents
You are required to show three EOI documents. Please provide details of your documents.
Category A (please print)
Document type (for example Qld Births, Deaths and Marriages(BDM) birth certificate)

Document number (for example C0100011)

Category B (please print)
Document type (for example Medicare card)

Expiry date (if applicable)

Category A or B (please print)
Document type

Document number or expiry type (do not give credit/debitcard number)

3. Evidence of Qld residential address (please print)

Note: If the CRN is being created for an agency card (for example, Blue Card), the address does not need to be in Qld)

Document type (for example utilities bill)

Issue date (for example 01/01/2023)

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4. Is your name different to the name/s on your EOI documents?
NoYes

You are required to show an EOI change of name document. Please provide details of your document.

Change of name (please print)
Document type (for example Qld BDM issued
marriage certificate)

Document number (for example 01000)

Registration year(for example 2001)

5. Are you getting a CRN to apply for an Agency Card?
NoYes

Which card are you applying for?
Blue Card
Disability Worker Screening Clearance Card
High Risk Work Licence

6. Applicant’s declaration
I declare that the information or documents given by me in this application are complete, true and correct in every detail.
I understand that I may be prosecuted if I have stated anything in this application that is false or misleading.
I consent to the Department of Transport and Main Roads (TMR) taking, keeping and using my personal information,documents, digital photo and digitised signature for the purposes of this application.
I consent to TMR verifying my EOI documents or information provided by me with the issuing authority or their agencies.
I understand that if I’ve completed this application for the purpose of an Agency card application, I may have to provide further
evidence of residency in the future.
I understand that if I do not have a TMR customer record, one will be created based on the information I have provided on theapplication form.
Applicant’s signatureDate//

It is an offence under the relevant transport Acts and the Photo Identification Card Act to state anything or give a document toan authorised person if you know it contains false or misleading information. Penalties apply.
Privacy Statement: TMR collects this information under the provisions of the Acts nominated on this form to manage the Qld driver licence, Industry Authority,marine licence, APA, Photo ID, vehicle and ship registers or to issue a product on behalf of an authorised agency. TMR may disclose this information and yourdigital photo to the Queensland Police Service. Information about a driver licence may be disclosed to interstate and foreign driver licensing authorities.
Information about an APA or Photo ID Card, pilot or escort vehicle driver accreditation, driver or rider trainer accreditation, traffic controller accreditation,
dangerous goods vehicle driver licence, or marine licence may be disclosed to interstate authorities that issue the relevant card, accreditation or licence. TMR’s
card production contractor will have controlled access to your information, digitised signature and digital photo to make your card. Information about your vehicle
and ship registration may be disclosed to interstate vehicle and ship registration authorities. Information, including your digital photo or digitised signature, may
be disclosed to an authorised agency if the information is connected to an application for its product. Your information will not be disclosed to any other third
party without your consent, unless required or authorised by law.

Office use only
Authorising person’s declaration
I have checked List Customer Images in TICA and confirmed the image status is valid.
Authorising person’s nameAuthorising person’s signature

Date//

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