958GOVERNMENT GAZETTE, W.A. [28 February, 1964.

958 GOVERNMENT GAZETTE, W.A. [28 February, 1964. P. 70. Application Pee Rec. No. Abstract No TRAFFIC ACT, 1919 APPLICATION FOR A DRIVER'S LICENSE I hereby apply for a License to drive a Motor and I furnish the No; QUESTIONS ANSWERS 'OF APPLICANT

1. What is your full name? (State Mr., Mrs., or Miss) .... SURNAME CHRISTIAN NAMES (Full name to be in Block Letters)
2. What is your permanent residence? (In full) ....
3. What is your temporary residence? .... ....
4. What is your occupation? ....
5. Where were you born? ....
6. What is your date of birth?
7. What is your description? .... Height ft inches
8. Have you previously held a Driver's License? If so, When was it first issued and where? ..... .... ..... 9: Have you ever applied for and been refused a License anywhere? .. - .... .... .... .... ....
9. Have you ever been disqualified from holding or obtain- . ins a License anywhere? .... .... . ....
10. Has your Driver's License ever been cancelled or sus- pendedanywhere? .... ... .... ....
11. Have you been convicted by ANY COURT of ANY OFFENCE? If so, give full' particulars - .... ,.:.,
12. Is your eyesight defective? If so, give particulars ....
13. Is your hearing defective? If so, give particulars..... so, give particulars .... .... .... • .... . ..,. ....
14. Do you suffer from epilepsy or fits? .... ....
15. Do you suffer from diabetes? .... .... .
16. Are you receiving insulin treatment? .... .... ....
17. Do you suffer from any complaint or disease which necessitates the taking of any • drug? If so, give 21, Have you any other physical or mental disability or- infirmity which could affect your efficiency in driving a motor vehicle? If so, give particulars of certify that all the particulars contained in this application are true and correct and that I suffer from no physical disability which would affect my efficiency in controlling a Motor PENALTY FOR FALSE OR MISLEADING INFORMATION: S25

28 February, 1964.] GOVERNMENT GAZETTE, W.A. 959 P. '70 (Reverse). (For Office Purposes Only.) To be filled in by Testing Members of the Force. -, A. Eyesight acuity test... (Without R. Eye 6/ Both eyes 6/ R. Eye 6/ - L, Eye 6/ 6/ B. Rearing test - • C. Traffic Regulation knowledge test .... .... ing all gears satisfactorily .... .... .... E. Turning vehicle in narrow street to proceed in opposite direction .... .... .... .... P. Reversing vehicle (other than motor cycle) in a confined space .... .... .... G. If driving a motor cycle and side car, making both left and right turns .... .... .... H. Road positioning at all times, whether driving forward or in reverse .... .... I. Giving codified signals wherever required by Regula tions .... J. Having control of and being able to stop vehicle quickly in case of emergency .... .... K. Stop and restart on a slope .... .... .... L. Park vehicle correctly, shift to neutral, apPly hand brake, stop motor — ''"• M. Any further test considered necessary by Examiner. (Give particulars) N.B.—CLASSIFICATION—Poor, Fair, Very Fair, Good. One classification of Poor or two of Fair will fail applicant for Signature Rank No Conditions License is issued under (if any) The Officer In Charge, Police Traffic Department, PERTH, License Number issued Date of Issue / /19 Date of Expiry / /19 Place of Issue