Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Home address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Gender *

Male

Female

Other

Pronoun

He/Him

She/Her

They/Them

Other

Do you identify as Culturally and Linguistically Diverse? *

Yes

No

Prefer not to say

Are you working? *

Yes

No

Are you currently studying? *

School student

Full time

Part time

I am not studying

Are you an Australian Citizen? *

Yes

No

Why do you require extra support to get a drivers licence? *

No proof of identity documents

No access to a car

No access to supervisor/driving instructor

Language and/or literact barriers

Financial support

Social, emotional and/or cultural barriers

Other

Do you currently have a drivers licence? *

No

Yes - manual

Yes - automatic

Which type of licence are you seeking? *

Automatic

Manual

Do you need help obtaining a learners permit? *

Yes

No

Tell us a bit about your driving experience. How many hours have you recorded in your logbook? *

Not required

None

1-20 hours

20-30 hours

30+ hours

Have you had any driving lessons with a professional driving instructor? *

Yes

No

Do you have any outstanding fines that could prevent you from getting a licence? *

Yes

No

Unsure

Karri Karrak Aboriginal Corporation will keep this information securely for the purposes of this program only. The information on this form will only be shared with the Department of Transport as and if necessary. All personal information provided will be treated as confidential and will not be used or disclosed without your consent, except where required or authorised by law, or where there is a risk of serious harm to yourself or others. I consent to KKAC holding this information for the purposes outlined above.

Yes