APPLICATION FOR REGISTRATION AS A DRIVESAFE NT INSTRUCTOR

DRIVING SCHOOL DETAILS

Office Use Only
Customer ID:

Date
received:

Accepted by:

Section 1 Individual Registration

To be completed by the individual seeking registration as a DriveSafe NT instructor.
Sole traders must complete both Section 1 Individual Registration and Section 2 Driving School Details
I hereby make application for:
Initial Registration

DriveSafe NT theory instructor

Re-Registration

DriveSafe NT practical instructor

Personal Details

First Name
Last Name
Email Address
Mobile Phone Number
Other Phone
Authorisation Number
Postal Address
Suburb

State

NT driver licence number

Expiry

Postcode

Operational Details
Driving school I will be representing
I am the registered owner of this business:

Yes

No

Region(s) I am applying to deliver DriveSafe NT training in:

Darwin

Katherine

Alice Springs

Tennant Creek

Declaration and Acceptance of Conditions of Registration

I hereby declare that;
1. As detailed within the Conditions of Registration for DriveSafe NT Instructors (the Conditions), all copies of required documentation and where
applicable, authorisations, are included in support of this application and the information that I have provided in support of my application is
true and correct in every particular.
2. I acknowledge that any payments or subsidies paid by DriveSafe NT will be paid to my nominated driving school, not me as an individual. Any
correspondence regarding DriveSafe NT payments will be sent to my nominated driving school.
3. Where I am employed by a driving school, I have satisfied myself that all requirements detailed in the conditions of registration for DriveSafe
NT instructors have been met, including provision of current insurance policies, vehicle requirements, vehicle registration and modification
certificates.
4. I have read and understood the Conditions of Registration for DriveSafe NT Instructors (the Conditions) which form part of this application and
I hereby agree to accept and at all times comply with, and be bound by, those Conditions for such time as I may be registered by DoT as a
DriveSafe NT instructor and provide any service in accordance with the DriveSafe NT program.
5. By signing this application for registration as a DriveSafe NT Instructor, I am also agreeing to follow DriveSafe NT policies and procedures,
including as they may change from time to time, relating to the delivery of the program.
Declared on the

day of

20

Applicant Signature

Name (please print)

Privacy Statement

The Department of Transport collects the information on this form, or otherwise provided by you, for the purpose of administrating the DriveSafe NT program. Failure to provide the information
requested on this form in full may result delays processing the application for DriveSafe NT registration or renewal.
Some of the personal information provided by you on this application may be publicly available as detailed in the Conditions of Registration for DriveSafe NT Instructors. The information may
also be provided to other NT Government agencies and Commonwealth Government Departments and agencies, as required by law.
Collection of personal information on this form is done in accordance with the privacy legislation contained within the Information Act. For more information please refer to the Department
Transports privacy statement located at www.nt.gov.au/ntg/disclaimer.shtml

APPLICATION FOR REGISTRATION AS A DRIVESAFE NT INSTRUCTOR

DRIVING SCHOOL DETAILS

Application Checklists: Individual (if renewing registration please check your renewal letter
for documents due)

Instructor - ALL
The following is provided with my application for registration as a DriveSafe NT instructor:
Completed Application form (Section 1 Individual Registration)
Copy of Apply first aid certificate or equivalent (initial registration and as required)
Certificate of current of insurance policies Public Liability and Public Indemnity
NOTE: May be provided by either the driving school or the individual
Current Working with Children (ochre card) clearance (initial registration and as required)
Current NT Police Criminal History record (initial registration and as required)
Traffic Offence History, not more than 6 weeks old
Evidence of citizenship or residency (if born outside of Australia) (initial registration only)
Contact details of at least three (3) referees with current contact details (initial registration only)

Instructor Practical
A current Northern Territory class C driver licence with a driving instructor endorsement
TLI41204 or TLI41210 Cert IV in Transport and Logistics (Road Transport Car Driving Instruction)
(initial registration only)
Evidence of 12 months experience as a practicing driving instructor within the past three (3) years
(initial registration only)

Instructor Theory
Copy of Certificate IV in Training and Assessment (or higher qualification in either training and
assessment or education) TAA40104 OR TAE40110 (initial registration only)
Evidence of at least six (6) months experience providing group training to 16 to 25 year olds
(initial registration only)
A current Northern Territory class C driver licence

APPLICATION FOR REGISTRATION AS A DRIVESAFE NT INSTRUCTOR

NEW DRIVING SCHOOL DETAILS
Office Use Only
Customer ID:

Date
received:

Accepted by:

Section 2 - Driving School Details

I hereby make application for:
Initial Registration

Re-Registration

Driving School Details

Business Name
Trading Name
Registered Owner Name
Business Email Address
Phone Numbers
Fax Number
Postal Address
Suburb

State

Postcode

State

Postcode

Residential Address
Suburb
Business ABN
Registered for GST?

Yes

No

Operational Details
Region(s) the driving school is applying to deliver DriveSafe NT training in:
Darwin

Katherine

Alice Springs

Tennant Creek

Instructors Associated With This Driving School

Instructor Name

Theory

Practical

1
2
3
4
5
6
Details Of Vehicles Intended To Be Used By The Driving School For DriveSafe NT Instruction
Registration #

Transmission

Manual / Auto

Manual / Auto

Manual / Auto

Manual / Auto

Manual / Auto

Manual / Auto

Vehicle Make and Model

APPLICATION FOR REGISTRATION AS A DRIVESAFE NT INSTRUCTOR

NEW DRIVING SCHOOL DETAILS

Application Checklists: Driving School

Completed form
Certificate of currency of insurance policies Public Liability and Public Indemnity
Note: May be provided by either the driving school or the individual
Extract of business registration from the Australian Business Register
(Initial Registration) May be provided by either the driving school or the individual
NT Government Supplier Payment form (Initial Registration or any bank changes)

Vehicle Details
For each vehicle intended to be used in the provision of DriveSafe NT instruction or assessment:
Current Certificate of Registration per vehicle
Certificate of modification issued by the Northern Territory Technical Advisory Committee for dual controls
(Initial Registration)
Roadworthy inspection report (if required)
Note: To be provided at time of annual registration of the vehicle (this may not align with DriveSafe NT registration /
renewal dates)
Evidence of comprehensive vehicle insurance for the purposes of professional driving instruction /
assessment

Declaration
I hereby declare that:
1. I am authorised to act on behalf of the business named above.
2. All copies of required documentation and where applicable, authorisations, are included in support of this application and the information is
true and correct in every particular.
3. I authorise the Department of Transport to use any documents or information provided as part of this application for individual(s) associated
with this driving school and registered as DriveSafe NT instructor(s) for the purpose of registration, renewal and ongoing compliance with the
DriveSafe NT program.
4. I acknowledge that any payments or subsidies paid by DriveSafe NT will be paid to the nominated driving school, not individual instructors.
Any correspondence regarding DriveSafe NT payments will be sent to the nominated driving school.

Declared on the

day of

20

Applicant Signature

Name (please print)

Privacy Statement

The Department of Transport collects the information on this form, or otherwise provided by you, for the purpose of administrating the DriveSafe
NT program. Failure to provide the information requested on this form in full may result delays processing the application for DriveSafe NT
registration or renewal.
Some of the personal information provided by you on this application may be publicly available as detailed in the Conditions of Registration for
DriveSafe NT Instructors. The information may also be provided to other NT Government agencies and Commonwealth Government
Departments and agencies, as required by law.
Collection of personal information on this form is done in accordance with the privacy legislation contained within the Information Act. For more
information please refer to the Department of Transports privacy statement located at www.nt.gov.au/ntg/disclaimer.shtml