RMS historic vehicle declaration

• The registered operator (or applicant) is responsible for the vehicle to be suitable for safe use until the expiry date of the registration.

• A Safety Check report must be provided if the club is less than two years old.

• The registered operator must be a member of an Roads and Maritime Services recognised club.

1) Registered operator details

NSW Driver's licence/Customer number:

Surname:

Given names:

Address:

Postcode:

Club membership details (nominate primary club first):

2) Vehicle details

Plate number (if known):

VIN or chassis/frame or serial number:

Engine number:

Make:

Model year:

Model (in full - name, letters and/or numbers, variant):

Shape:

Vehicle type:
Car/Station WagonMotorcycleTruckTrailerBusPlantOther

Please specify:

3) Declaration (to be completed by club official)
A Safety Check report must be provided if the club is less than two years old)
The vehicle is in a safe operating condition.

Name:

Signature:

Position held in club:

Date:

Or

Safety Inspection report number:

Date:

4) Vehicle eligibility(to be completed by club official)

• I certify that this vehicle meets the eligibility criteria for an historic vehicle registered under the Conditional Registration scheme.

• The registered operator is a financial member of the club.

Name:

Signature:

Position held in club:

Date:

Club stamp:

ABN 76 236 371 088 Catalogue No. 45070967, Form No. 1259 (03/2014)