Application for Authorisation as a LPG or LPG/CNG Examiner

AIS - Application for Authorisation
as an LPG, CNG or LPG/CNG Examiner
Note: This form is to be used for Authorised Examiners that hold an existing Motor Vehicle Repair Industry Authority (MVRIA) LPG
and/or CNG Mechanics certificate and are applying to be authorised to inspect gas powered vehicles.
1
Applicant details (Please use block letters)
2
Authorised Examiner number
Details of Motor Vehicle Repairer
Authority (MVRIA) accreditation
Industry
MVRIA LPG and / or CNG Mechanics Certificate Number
(A copy of your Certificate MUST be attached to this
application)
Surname
Examiner Accreditation
(Please tick relevant boxes)
Given names (All names required)
LPG only
CNG only
Residential address
(Include street, street number, suburb/town and postcode)
LPG / CNG
Date on MVRIA LPG/CNG Certificate
day
/
month
/
year
Postcode
3
Mailing address (If mailing address same as residential
address insert 'as above')
Postcode
Day time contact phone number
Mobile
Declaration
Personal Information is collected and held by the Roads and
Maritime Services (RMS), 101 Miller Street, North Sydney
NSW 2060.
I must supply the information under the Road Transport Act
2013. Failure to supply full details, relevant documentation
and sign the declaration can result in the application not
proceeding. My 'Personal Information' held by RMS may be
disclosed inside and outside NSW to driver licencing and
vehicle registration agencies and law enforcement agencies
to verify the contents of this application. I consent to the
disclosure of information needed to verify the contents of
this form.
I declare that the details in this application are correct and
complete.
Signature (Applicant must sign)
Email address
Date
Date of birth
day
/
month
/
day
/
month
/
year
year
Drivers licence number (this information must be provided)
Please return this form to:
Enrolment Processing Glen Innes
PO Box 122, Glen Innes NSW 2370
T 1300 79 11 86
F 1300 79 38 65
E [email protected]
Catalogue No. 45071356, Form No. 1452 (01/2015) ABN 76 236 371 088
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