Removal of licence
disqualification
Part 2 – Form and affidavits
32 St Georges Terrace
PERTH WA 6000
InfoLine: 1300 650 579
www.legalaid.wa.gov.au
Introduction
This is Part 2 of Legal Aid WA’s Removal of licence disqualification kit and includes the form and
affidavits to be used if you are applying to have your driver’s licence disqualification removed.
BEFORE USING THE FORM AND AFFIDAVITS please read Removal of licence disqualification
– Part 1 – Information kit, which provides important information about when and how you may
apply and how the form and affidavits should be used.
Form and affidavits
The form and affidavits included here have been adapted specifically for use in applying to remove
a licence disqualification. They have also been specifically adapted for an application in the District
Court. If your application is in the Supreme Court, each form and affidavit needs to be amended to
read “Supreme Court” instead of “District Court”.
The form and affidavits are provided in Word format, so you may download and complete them
electronically before printing. If you print the blank documents to complete them by hand, be aware
that some parts must still be provided in typed format. Refer to the instructions for completing these
documents in Part 1 of the kit.
The following form and affidavits are included here:




Form 104: Application for removal of disqualification
Affidavit and annexures (yours)
Affidavit and annexures (witness’)
Affidavit of service and annexures
Disclaimer and Copyright
Copyright © Legal Aid Western Australia 2015. Any part of this publication may be copied,
reproduced or adapted to meet local needs by community based organisations without permission
from Legal Aid Western Australia provided the copies are distributed free or at cost (not for profit)
and the source is fully acknowledged. For any reproduction with commercial ends or by government
agencies, permission must first be obtained from Legal Aid Western Australia.
This Kit provides information about the law only and does not constitute legal advice. You should
seek legal advice if you have a specific legal problem.
Every effort is made to ensure that the information contained in this Kit is correct as at the date of
publication. However, please note that the law may change at any time and may impact on the
accuracy of this information. Legal Aid WA accepts no responsibility for any inaccuracies, errors or
omissions in this information or incorporated into it by reference.
104.
Application for removal of disqualification (O. 81C r. 2(4))
Road Traffic (Authorisation to Drive)
Act 2008 (WA) s. 24(1)
District Court of Western Australia
No:
Applicant
APPLICATION FOR REMOVAL OF
DISQUALIFICATION
Full name
Address
Date of birth
Occupation
Details of order
disqualifying
applicant from
holding
or
obtaining
a
driver’s licence
Court that made the
order
Date of order
Period disqualified
Reason1
Application
Grounds
this
application2
Certificate
applicant
Signature
applicant
Under the Road Traffic Act 1974 (WA) s 78, I apply for an order removing the
above disqualification.
for 1.
by An application made under the Road Traffic (Authorisation to Drive) Act 2008
(WA) s. 24(1) in respect of the above disqualification has not been refused in
the year preceding the date of this application.
of
Date
Hearing details This application will be heard —
on [date]
at [time] or as soon after as possible,
at [place]
Notes to Form No. 104 —
1.
State the offence(s) for which the applicant was disqualified and, if the offence was against
the Road Traffic Act 1974 (WA) s.63, 64, 67 or 67A, state whether the conviction was the
applicant’s first, second or subsequent for the offence. If disqualified for some other reason,
give details.
2.
Note the Road Traffic (Authorisation to Drive) Act 2008 (WA) s. 24(5). Use numbered
paragraphs.
TO:
The Respondent
The Director General of Transport
GPO Box R1290
PERTH WA 6844
IN THE DISTRICT COURT OF WESTERN AUSTRALIA
HELD AT
MC No.
of 20
IN THE MATTER of section 24(1) of the Road Traffic (Authorisation to Drive) Act 2008 (WA))
and
IN THE MATTER of an application to remove a disqualification from holding a motor driver's
licence
B E T W E E N:
Applicant
- and The Director General of Transport
Respondent
AFFIDAVIT OF
(Applicant)
TOGETHER WITH ANNEXURES
SWORN IN SUPPORT OF APPLICATION FOR AN ORDER REMOVING
DISQUALIFICATION
Date of signing:
Date of filing:
Filed by:
Name:
The Applicant
(Applicant’s name)
Address:
Telephone:
Annexures
Annexure
Description
Page No:
____________________________________________
I,
(Applicant’s name)
of
(Applicant’s address)
in the State of Western Australia,
(Applicant’s occupation)
being duly sworn make oath and say/do solemnly and sincerely declare and affirm as follows:
1. I am the applicant. I swear/affirm this Affidavit in support of my application to remove my
disqualification from holding or obtaining a motor drivers licence.
2. The information deposed to in this affidavit is true to the best of my knowledge.
3.
The disqualification which I am applying to set aside was imposed by the
Court at
(Magistrates Court or District)
on the
(Place)
.
(Date)
4. Annexed to this Affidavit and marked with the letter “A” is a copy of my history for court
document (criminal history).
5. Annexed to this Affidavit and marked with the letter “B” is a copy of my record of traffic
infringement notices (delete if you do not have a record of traffic infringement notices).
6. Attached to this Affidavit is:
(Any other relevant document eg. Extraordinary driver’s licence)
7. The circumstances leading up to me committing the offence and the circumstances of the offence
itself for which I received my licence disqualification, were as follows:
8. As to the other offences on my history for court document (criminal history), the circumstances
were as follows:
9. At the time of committing the offences on my history for court document (criminal history), I was
a drinker of alcohol to the following extent:
(Set out frequency, degree and amount of alcohol usage - how much, how often)
10. At present, I am a drinker of alcohol to the following extent:
(Set out frequency, degree and amount of alcohol consumed)
11. Despite my traffic convictions, I am no longer a danger to the public when driving a motor vehicle
for the following reasons:
12. My personal circumstances are as follows:
Date of birth:
Marital status:
Number of dependant children and
ages:
Occupation:
Spouse’s / defacto’s occupation:
Any other relevant personal information:
13. My financial position is as follows:
Applicant
Income
Weekly income and source
Net wages
Centrelink benefit
Other sources of income (amount and type)
Total weekly income
$
Expenses
Weekly expenses
Mortgage payments
Board or rent
Other expenses (list)
Total weekly expenses
$
Assets
Home
Other land
Motor vehicle
Money in banks
Money in building societies
Cash on hand
Any other assets (list)
Total value of assets
$
Liabilities (debts)
Give details:
Total liabilities
$
Spouse
or
defacto
14. My work history, including periods of unemployment, is as follows:
15. The reasons why I would like to have my driver’s licence back are as follows:
16. The further information which I would like to put in support of my application is as follows:
SWORN by the abovenamed
deponent at
in the State
of Western Australia this
day
of
20
Before me:
Signature of authorised witness
Name of authorised witness
Occupation of authorised witness
)
)
)
)
)
IN THE DISTRICT COURT OF WESTERN AUSTRALIA
HELD AT
MC No.
of 20
IN THE MATTER of section 24(1) of the Road Traffic (Authorisation to Drive) Act 2008 (WA)
and
IN THE MATTER of an Application to remove a disqualification from holding a motor driver's
licence
B E T W E E N:
Applicant
- and The Director General of Transport
Respondent
AFFIDAVIT OF
(Name)
TOGETHER WITH ANNEXURES
SWORN IN SUPPORT OF APPLICATION FOR AN ORDER REMOVING
DISQUALIFICATION
Date of signing:
Date of filing:
Filed by:
Name:
The Applicant
(Applicant’s name)
Address:
Telephone:
Annexures
Annexure
Description
Page No:
____________________________________________
I,
(Witnesses name)
of
(Witnesses address)
in the State of Western Australia,
(Witnesses occupation)
being duly sworn make oath and say/do solemnly and sincerely declare and affirm as follows:
1. I swear/affirm this affidavit in support of the application of
remove his/her disqualification from holding or obtaining a motor driver's licence.
to
2. Annexed to this affidavit is my letter / reference / report in support of the application.
3. The contents of my letter / reference / report are true to the best of my knowledge and belief.
SWORN by the abovenamed
deponent at
in the State
of Western Australia this
day
of
20
Before me:
Signature of authorised witness
Name of authorised witness
Occupation of authorised witness
)
)
)
)
)
Signature of deponent
IN THE DISTRICT COURT OF WESTERN AUSTRALIA
HELD AT
MC No.
of 20
IN THE MATTER of section 24(1) of the Road Traffic (Authorisation to Drive) Act 2008 (WA)
and
IN THE MATTER of an Application to remove a disqualification from holding a motor driver's
licence
BETWEEN:
Applicant
- and The Director General of Transport
Respondent
AFFIDAVIT OF SERVICE OF________________________
(Name of person)
Date of signing:
Date of filing:
Filed by:
Name:
The Applicant
(Applicant’s name)
Address:
Telephone:
Annexures
Annexure
Description
Page No:
____________________________________________
I,
(Applicant’s name)
of
(Applicant’s address)
in the State of Western Australia,
(Applicant’s occupation)
being duly sworn make oath and say/do solemnly and sincerely declare and affirm as follows:
1.
On
I served the Director General of Transport with
(date)
the application to remove disqualification by hand.
SWORN by the abovenamed
deponent at
in the State
of Western Australia this
day
of
20
Before me:
(Signature of authorised witness)
(Name of authorised witness)
(Occupation of authorised witness)
)
)
)
)
)
(Signature of deponent)