Last name:
First name: Other names
(if any):
Residential
address:
Only NSW residents may apply (see note 3 in General Information)
Postcode:
Postal address
(if different):
Postcode:
Daytime contact telephone number
and/or mobile number:
/
Driver licence number: Licence
Class:
Issuing
State:
Date of Birth:
Email address:
Correspondence, including renewal notices, will be sent electronically if you provide an email address
Existing current dangerous goods driver licence number (if renewing):
Driving History - You are required to provide records of your driving history covering at least the last 5 years, from each
licensing authority that issued you with a driving licence during that time, including overseas (copy of o/s photo licence should be
supplied).
Have you held a driving licence (other than the one detailed above) issued in another State or Territory during the last 5 years?
NO YES If yes, State/Territory of issue: (driving histories to be provided)
Have you had any driving licence disqualified, cancelled or suspended during the last 5 years?
NO YES If YES, you may have an unsatisfactory driving history (see note 10 under General Information).
Please note: holders of a Provisional driver licence (P Plates) are NOT ELIGIBLE for a NSW DG Driver Licence
Declaration
a) The attached record/s of my driving history are copies that have been issued and certified by the driving licensing authorities.
b) I consent to the Environment Protection Authority (EPA) having access to the records relating to my driving history held by
NSW Roads and Maritime Services and other driving licence authorities for the purposes of this application or in relation to
any dangerous goods licence subsequently granted to me by the EPA.
c) I consent to the EPA contacting the reporting medical practitioner in regard to information supplied on the Medical
Assessment Certificate.
d) I declare that the details shown in this application are true and correct and that I have read and understood the General
Information section of this form.
Signed: Date:
It is an offence for a person to provide any information or make any statement in this form that is false or misleading.
There is a maximum penalty of $60,000 for this offence.
ABN 43 692 285 758
APPLICATION FOR DANGEROUS
GOODS DRIVER LICENCE
Form DG1/08-2018
Tax invoice
Dangerous Goods (Road and Rail Transport) Act 2008
Office use only File ref no:
DGD
2 DG1/08-2018
CERTIFICATION OF TRAINING - TO BE COMPLETED BY THE RELEVANT REGISTERED TRAINING ORGANISATION
I certify that the TLILIC0001 Course in Transport of Dangerous Goods by Road is listed on this
successfully completed the mandatory
assessment instrument (MAI).
Trainee Name:
.
Dates of c
Signature of person authorized to sign on behalf of the RTO Date
Payment details
Payment can be made by credit card or EFT. Please note: a card merchant fee of 0.4% applies.
Visa Mastercard Cheque Money order
Card Number: _ _ _ _ / _ _ _ _ / _ _ _ _ / _ _ _ _
_ _ _ _ __ _ _ _ __ _ _ __ __ _ _ __ _ ___ _ _ __ __ _ _ ___ _ _ ___ _ _ __
Expiry: _ _ / _ _ Amount: $_ _ _ _ _ __ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ __ _ _ ___ _ _ ___ _ _ ___ _ _ ___ _ _ __
Contact cardholder
Telephone/email: ( )_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ __ _ _ _ __ _ _ _ __ _ _ _ __ _
Payment by Electronic Funds Transfer (EFT) should be deposited to:
Bank:
Westpac Banking Corporation
Account Name: EPA Operating Account
BSB:
032 001
Account No: 170 737
Reference
Applicant
name
DGD
Remittance for EFT payments should be e-mailed to dgrp.lice[email protected].gov.au
3 DG1/08-2018
Guidelines for completing form
Applicant must:
complete Section 1 Patient Questionnaire in the attached
Health Assessment Report;
make an appointment with a registered medical practitioner of
his/her choice;
take spectacles, hearing aids, etc to the examination;
take all current medication, or a complete list of such
medication, to the examination; and
take photo identification to the examination.
Examining medical practitioner must:
read Part A and the Commercial Standards sections of Part
B of the document
(for
guidelines go to www.austroads.com.au);
review completed Section 1 of the attached Health
Assessment Report with the applicant;
complete Section 2;
complete the Medical Certificate below.
Applicant Personal Details
Family Name:
Given Names:
Date of Birth: Male / Female (circle)
Driver Licence No: Class:
Medical Certificate to be completed by registered medical practitioner
Medical practitioner please note: Tick only ONE box below and do not add any comments
I certify that I have examined this person in accordance with the National Medical Standards for Commercial vehicle drivers as set
out in Assessing Fitness to Drive (current edition) and I have sighte
. In my opinion, the
person who is the subject of this certificate:
Meets the relevant medical criteria for an unconditional
medical review (Note: a medical review is required every 5
years on renewal of a dangerous goods driver
licence)
Meets the relevant medical criteria for a conditional
commercial licence, however a periodic medical
review is not required for at least 5 years (see last paragraph of note 7 under General Information)
Meets the relevant medical criteria for a conditional commercial licence and a periodic
medical review is
required annually
Does
not
meet the medical criteria for an unconditional commercial licence or a conditional commercial
licence.
Signature of reporting medical practitioner:
Date of examination:
Practice Address:
STAMP of registered medical practitioner below
Telephone No:
( )
Fax:
( )
Medical Fitness to Drive Assessment
4 DG1/08-2018
GENERAL INFORMATION
1 Do you need a licence?
A person must have a dangerous goods driver licence if
transporting:
(a) dangerous goods that are in a receptacle with a capacity of
more than 500L, or
(b) more than 500kg of dangerous goods in a single receptacle,
or
(c) in the case of intermediate bulk containers (IBCs), where the
total capacity of all IBCs is more than 3,000L or where any IBC
is filled or emptied while on a vehicle
Apply online via eConnect EPA:
https://apps.epa.nsw.gov.au/epabusinessportal/dgdl-login
2 Suitability of applicant
The EPA will issue a dangerous goods driver licence only to an
applicant who has completed the mandatory assessment, who is
medically fit and who has a
satisfactory
driving history.
Please note that holders of a Provisional driver licence
(P plates) are
NOT ELIGIBLE
for a NSW dangerous goods
driver licence.
3 Applicant MUST be a NSW resident
States and Territories can only issue licences to persons who
reside in that State or Territory. Proof of residency may be
required in the form of rental agreement, rate notice or utility bill.
4 Evidence of training
The applicant must have successfully completed the TLILIC0001
mandatory assessment, conducted by an RTO not more than 6
months before the day when the licence application is received
by the EPA. A person authorised by the RTO must sign the
certificate on the second page of this application form.
5 Licence renewals
You may renew your NSW dangerous goods licence by
completing this application and supplying the required evidence
of training, medical fitness and satisfactory driving history. The
quickest way to renew your licence is online via eConnect EPA
https://apps.epa.nsw.gov.au/epabusinessportal/dgdl/renew
6 Medical examination
A satisfactory health assessment certificate is required as part of
the application. A registered medical practitioner must complete
a medical assessment certificate. Payment for the medical
examination is the responsibility of the applicant and is not
usually covered by a rebate under Medicare.
7 Medical assessment certificate
An acceptable medical assessment certificate is one of the
following:
(a) The medical assessment certificate which is part of this
application form -Assessing Fitness to Drive (current edition);
(b) The Medical Report form of NSW Roads & Maritime Services
(c) The Public Passenger Vehicle Driver Medical Assessment
Certificate of the NSW Ministry of Transport; or
(d) The Medical Certificate of the TruckSafe Accreditation
Program of the Australian Trucking Association
The medical assessment certificate is acceptable only if it
was issued not more than 6 months before the day when the
new licence application is received by the EPA, and in the
case of medical renewal within 6 months of the licence
expiry date.
Note that if the medical assessment certificate indicates that the
driver meets the criteria for a conditional licence but no medical
review is required, the EPA will issue a standard 5 year
dangerous goods driver licence.
8 Proof of identity
The applicant must provide:
(a) a legible copy of his/her current vehicle driving licence
(front and back), and
(b) 2 recent passport sized colour photographs
- see www.passports.gov.au for guidelines & taken
within last 6 months.This photo will be used to create
DG Driver photo ID card
9 Driving history
An applicant is required to have a satisfactory driving history. The
EPA requires a copy, issued and certified by the appropriate
last 5 years. Drivers who have held a licence in Western Australia
during that period should also include a National Police
Certificate as part of their complete driving history. Where a
licence has been held overseas during that period a certified
copy of the photo licence (front and back) should be provided
along with a National Police Certificate.
The driving history must have been issued not more than 6
months before the day when the licence application is received
by the EPA. Each driving licence authority can provide a copy of
driving history in some form. In NSW, the authority is
NSW Roads & Maritime Services (formerly the RTA).
Please note that EPA does not accept uncertified driving
records downloaded from the RMS website for dangerous
goods driver licensing purposes.
10 What is an unsatisfactory driving history?
The EPA will not grant a dangerous goods driver licence unless
the applicant's driving history is satisfactory. The following are
considered to be an unsatisfactory driving history and the
applicant will NOT generally be granted a dangerous goods
driver licence:
(a) Any driver who has had any driving licence (issued in NSW
or elsewhere) suspended or cancelled or who has been
disqualified from driving, (apart from a loss of licence
relating to the non-payment of fines) more than once
during the last 5 years; or
(b) Any driver who has had any such driving licence suspended
or cancelled or if they have been disqualified from driving
once during the last 5 years, where found guilty of a traffic
offence (in a court of law in Australia) such as:
Dangerous driving;
Negligent driving;
Drug and or alcohol related offences; or
Any other offence which the EPA considers to be
relevant.
If you consider that you might not be eligible to obtain a
dangerous goods driver licence, for example because of a driving
licence cancellation, suspension or disqualification during the
last 5 year period, you should contact the EPA before you
undertake the training course.
11 Licence application fee
The application fee for a new licence or a renewal is $63*.
Payment may be made by card (VISA and Mastercard cards
only) or EFT as detailed on page 2.
*Please note: a merchant card payment fee of 0.4% applies.
The fees set out in this application are GST exempt by the Federal
Treasurer's determination under Division 81 of A New Tax System
(Goods and Services) Act 1999.
5 DG1/08-2018
12 Training course fee
The provider of the dangerous goods training course will charge
a fee for the course. The course fee is set by the provider and is
separate from the EPA dangerous goods driver licence
application fee.
13 Duration of licence
Dangerous goods driver licences are normally issued for a period
of 5 years. Some may be issued for 1 year, depending on the
medical assessment or driving history submitted.
14 Issuing of licences
The EPA does not provide a service for the issue of licences
over the counter and cannot guarantee the immediate issue of
any driver licence. The EPA aims to issue a licence within 20
working days of receipt of all information required for the licence
application.
The quickest way to apply for a licence is online via eConnect
15 Personal information and privacy
The details that you provide on this application form are required
by law.
Details of all licence applications including personal information
such as your name and date of birth are collected and held by
the EPA and some details are made available to the public, along
with licence details, via the public register (see note 18).
You can ask the EPA to remove or not place personal information
on the public register. However, for this to occur the EPA must
be satisfied that the safety or well being of any person would be
affected by not suppressing the information and that suppression
would, on balance, be in the public interest. You can forward
reasons why your personal information should not be included
on the public register to the Head Regulatory and Compliance
Support, Environment Protection Authority,
.
The information received by EPA in this application is
maintained in accordance with the Government Information
(Public Access) Act 2009 (GIPA Act). You have the right to
access the information EPA is holding about you. You can also
require EPA to make appropriate amendments (whether by way
of corrections, deletions or additions) to ensure that the personal
information is accurate, relevant, up-to-date, complete and not
misleading. Contact a Right to Information Officer, Environment
Protection Authority,
(02 9995 6080 or 02 9995 6497) for assistance.
16 Sending the application
Forward the complete licence application to:
Licensing and Compliance Unit
Environment Protection Authority
Note: Some trainers will collect all the information required, as
well as the EPA licence application fee, and forward the complete
application to the EPA on behalf of the applicant.
17 Contact us
Email:
Telephone:
[email protected]
131 555 (from NSW only)
02 9995 5
18 Web site/public register
To access further information regarding dangerous goods
transport, to download forms, or for a link to the public register
of licences visit: https://www.epa.nsw.gov.au/your-
environment/dangerous-goods
19 eConnect
To apply for a Dangerous Goods Driver licence online visit:
http://www.epa.nsw.gov.au/epabusinessportal/dgdl-login
You will need to provide ALL of the information as detailed in this
application form when applying online.
BEFORE SENDING THIS APPLICATION
Please ensure that the following have been completed or are
attached to the application:
All applicant details on page 1;
The RTO certification on page 2;
The Medical Assessment Certificate on page 3 (or
other acceptable assessment certificate)
see note 7;
A legible copy of your driving licence (front and back);
Where an interstate dangerous goods driver licence
has been held, a legible copy of that licence;
Two passport sized colour photos (please print name
on reverse side and do not staple through face);
Driving history report or reports covering at least the
last 5 years
see note 9;
Where an overseas driver licence has been held
during the last five years, a legible copy of that photo
licence (front and back) and a
National
Police Certificate; and
WA drivers should include a National Police Certificate
as part of their complete driving history
The licence application fee see note 11.
If you fail to provide the required information or attachments,
your licence application will not be able to be properly
assessed by the EPA and may be returned to you for
amendment or your application refused.
6 DG1/08-2018
Health Assessment Report Section 1 - Patient Questionnaire
Please answer the questions by ticking the correct box. If you are not sure, leave the question blank and
ask your medical practitioner what it means. The medical practitioner may ask you additional questions
during the examination.
This report is NOT to be returned to the EPA with the completed application form.
No Yes
1. Are you currently being treated
by a medical practitioner for any
illness or injury?
2. Are you receiving any medical treatment
or taking any medication (either
prescribed treatment or otherwise)?
Please take any medication with
you to show the doctor
3. Have you ever had, or been told by a medical
practitioner that you had any of the following?
No Yes
3.1 High blood pressure
3.2 Heart disease
3.3 Chest pain, Angina
3.4 Any condition requiring
heart surgery
3.5 Palpitations/Irregular
heartbeat
3.6 Abnormal shortness
of breath
3.7 Head injury, Spinal injury
3.8 Seizures, Fits
Convulsions, Epilepsy
3.9 Blackouts, Fainting
3.10 Stroke
3.11 Dizziness, Vertigo
Problems with balance
3.12 Double vision,
difficulty seeing
3.13 Colour blindness
3.14 Kidney disease
3.15 Diabetes
3.16 Neck, back or limb
disorders
3.17 Hearing loss or deafness
or had an ear operation
or use of hearing aid
3.18 Do you have difficulty hearing
people on the telephone (including
if using a hearing aid?
3.19 Have you ever had, or been told
by a medical practitioner that you
have a psychiatric illness, or
nervous disorder?
No Yes
3.20 Have you ever had any other serious
injury, illness, operation or been in
hospital for any reason?
4.1 Have you ever had, or been told by a
medical practitioner that you have had a
sleep disorder, sleep apnoea,
or narcolepsy?
4.2 Has anyone noticed that your breathing
stops or is disrupted by episodes of
choking during sleep?
4.3 How likely are you to doze off or fall sleep
in the following situations, in contrast to
feeling just tired?
Use the following scale to choose the
most appropriate number for each
situation below:
0 would never doze off
1 slight chance of dozing
2 moderate chance of dozing
3 high chance of dozing
It is important that you put a number (0
to 3) in each of the 8 boxes.
Situation Chance of dozing (0-3)
Sitting and reading...........................
Watching TV....................................
Sitting inactive in a public place .......
As a passenger in a car for an hour
without a break ...............................
Lying down to rest in the afternoon..
Sitting and talking to someone.........
Sitting quietly after a lunch without
alcohol.............................................
In a car, while stopped for few
minutes in the traffic.........................
7 DG1/08-2018
Part 5 questions please tick the answer that is
correct for you
5.1 How often do you have a drink containing
alcohol?
Never (if never, go to question 6)
Monthly
2-4 times a month
2-3 times a week
5 or more times a week
5.2 How many drinks containing alcohol do
you have on a typical day when you are
drinking?
1 or 2 3 to 5 5 to 6
7 to 9 10 or more
5.3 How often do you have six or more drinks
on one occasion?
Never Less than monthly
Monthly Weekly
Daily or almost daily
5.4 How often during the last year have you
found that you were not able to stop
drinking once you had started?
Never Less than monthly
Monthly Weekly
Daily or almost daily
5.5 How often during the last year have you
failed to do what was normally expected
from you because of drinking?
Never Less than monthly
Monthly Weekly
Daily or almost daily
5.6 How often during the last year have you
needed a first drink in the morning to get
yourself going after a heavy drinking
session?
Never Less than monthly
Monthly Weekly
Daily or almost daily
5.7 How often during the last year have you
had a feeling of guilt or remorse after
drinking?
Never Less than monthly
Monthly Weekly
Daily or almost daily
5.8 How often during the last year have you
been unable to remember what happened
the night before because you had been
drinking?
Never Less than monthly
Monthly Weekly
Daily or almost daily
5.9 Have you or someone else been injured
as a result of your drinking?
No
Yes, but not in the last year
Yes, during the last year
5.10 Has a relative, friend, doctor or other
health worker been concerned about your
drinking or suggested you cut down?
No
Yes, but not in the last year
Yes, during the last year
No Yes
6. Do you use illicit drugs?
7. Do you use any drugs or
medications not prescribed for
you by a medical practitioner?
8. Have you been in a vehicle
crash since your last licence
examination?
medical practitioner)
(Print Name)
I certify that to the best of my knowledge the above
information supplied by me is true and correct.
Date:
IMPORTANT
For privacy reasons the completed
Questionnaire must NOT be returned to the EPA.
Medical information relevant to driver licensing should
be included on the Medical Certificate on page 3
8 DG1/08-2018
Health Assessment Report Section 2 - Medical Practitioner to Complete
Applicant name:
For privacy reasons this report is for medical review purposes only and is to be kept by the medical practitioner for
record purposes. This report is not to be returned to the
EPA
with the completed application form.
1. Cardiovascular System:
1.1 Blood Pressure (repeat if necessary)
Systolic mm Hg mm Hg
Diastolic mm Hg mm Hg
1.2 Pulse Rate:
Regular
Irregular
1.3 Heart Sounds:
Normal
Abnormal
1.4 Peripheral Pulses:
Normal
Abnormal
2. Chest/Lungs:
Normal
Abnormal
3. Abdomen (liver):
Normal
Abnormal
4. Neurological/Locomotor:
4.1 Cervical spine rotation
Normal
Abnormal
4.2 Back Movement
Normal
Abnormal
4.3 Upper Limbs
(a) Appearance
Normal
Abnormal
(b) Joint Movements
Normal
Abnormal
4.4 Lower Limbs
(a) Appearance
Normal
Abnormal
(b) Joint Movements
Normal
Abnormal
4.5 Reflexes
Normal
Abnormal
4.6
Normal Abnormal
(*A pass requires the ability to maintain
balance while standing with shoes off, feet
together side by side, eyes closed and arms by
sides, for thirty seconds)
5. Vision:
5.1 Visual Acuity
Uncorrected Corrected
R L R L
6/ 6/ 6/ 6/
Are contact lenses worn?
No
Yes
5.2: Visual Fields (Confrontation to each eye):
Normal
Abnormal
6. Hearing: Normal Abnormal
7. Urinalysis
7.1 Protein Normal
Abnormal
7.2 Glucose Normal Abnormal
8. Neuropsychological Assessment
Where clinically indicated apply the Mini
Mental State Questionnaire or General Health
Questionnaire or equivalent
Score
Relevant Clinical Findings
Note comments on any relevant findings
detected in the questionnaire or examination,
making reference to the requirements of the
standards outlined in the AFTD publication.
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
Note: The medical practitioner may extend the examination
where considered clinically appropriate, but must
advise the applicant of any extra cost. The medical
practitioner may also refer the applicant to a specialist
for further examination.
Sign:
Date: