Learner Driver Application Form Section A – Applicant Details Title:MrMrsMsMiss Gender:MaleFemale Address: ACTNSWNTQLDSATASVICWA Postal Address: (if different to above) ACTNSWNTQLDSATASVICWA Are you an Australian citizen or permanent resident? YesNo Do you give Pacific Link and your parent/guardian permission to contact each other about your application? YesNoNot Applicable YOUR CONNECTION TO COMMUNITY HOUSING Please provide the details of the person who is the main tenant in your household. Title:MrMrsMsMiss If you are unsure of these details, contact the office n 4324 7617 or 1300 654 973 toll free for further advice Section B – Additional Information Note: this information will help us better understand your reasons for applying for the Learner Driver Program How many driving hours do you currently have registered in your log book? (You need 70 hours to be eligible for the free lessons) Do you wish to apply for a loan from Pacific Link Housing to pay for driving lessons to increase your hours to 70? YesNo If you answered yes, you will need a loan application. Please contact the office for further information. Which type of vehicle do you wish to learn to drive in? AutomaticManual Are there any restrictions to your Licence? NoIf Yes, please specify: Please state your preferred times for lessons i.e. weekends; after school hours; mornings etc. Are you of Aboriginal or Torres Strait Islander origin? NoAboriginalTorres Strait Islander From a language background other than English? NoIf Yes, please specify: Do you have a disability? NoIf Yes, please specify: Do you currently have a vehicle or access to a vehicle to learn to drive in? YesNo Do you have a computer with the internet connected or access to one? YesNo How did you find out about the Learner Driver Program? i.e. newsletter, website, another tenant, PLH staff SECTION C – Applicants Statement Please tell us in your own words what the learner driver program would mean to you? Are there any other special circumstances that you haven’t mentioned? Section D – Applicant Declaration Note: this section must be completed by the applicant or a parent or guardian if applicant is under 16 years. Name of learner driver: Provision of Personal Information I certify that the personal information provided in this application is correct YesNo I am over the age of 16 years (if you tick ‘no’ your parent/guardian must sign this form) YesNo Administer and disburse the Learner Driver Program fundsI give permission for Pacific Link Housing to collect use and disclose my personal information in this application form only for the purposes of assessment and administration of the Learner Driver Program. Without this permission, it will not be possible to award the Scholarship. YesNo Release of details for Publicity There may be situations where your personal details cannot be released to the public. Consent to publicity and/or public release of personal details in the media is voluntary and will not affect the assessment of applications. If I win the Learner Driver Program, I give permission for Pacific Link to use and release my first name (second name only with written consent) and a description of the Learner Driver Program along with my success story for publicity purposes. YesNo If I win the Learner Driver Program, I give permission for Pacific Link to use any photographs of me (e.g. from presentation ceremonies) for publicity purposes. YesNo Students who are 16 years of age or older at the time of this application, may sign this declaration. Where a student is under 16 years of age, this form must be signed by the student’s parent or guardian. Name: Address: ACTNSWNTQLDSATASVICWA Contact Phone Number: Date: Sign Here > Use your computer mouse to sign in the signature box. If you are on a mobile device you can use your finger. GUIDELINES TO COMPLETING THE APPLICATION FORM Section A - Applicant details (compulsory information) In this section, fill in the full details of the person applying for the Learner Driver Program. Full details are required as incomplete forms may not be considered any further. Date of birth – Fill in your date of birth. If you are aged under 16 years, please include the name and contact details of your parent/guardian. Australian citizen/permanent resident – You must be an Australian citizen or permanent resident to be eligible for the Pacific Link Scholarship. Section B - Additional Applicant Information (optional information) Please indicate if you: - are Aboriginal and/or Torres Strait Islander - are from a language background other than English - have a disability You may like to tell us about any previous awards you have received. This will provide us with further background information. Section C – Applicant’s Statement (compulsory information) Completing the statement – You, the learner driver, must complete the questions describing how you would benefit from receiving the Learner Driver Program. Space is provided on the application form to write your statement. Provide enough information in this section to fully answer each question. This is the information we will use to assess your application. Section D – Applicant’s Declaration (compulsory information) Provision of personal information – It is compulsory for you, the learner driver, to certify that the personal information provided in the application form is correct. If this is not acknowledged, the application may not be considered any further. Provision of personal information to administer and disburse learner driver program funds – It is compulsory for you, the learner driver, to acknowledge that information from the application form (including personal details) will be collected, used and disclosed by Pacific Link Housing only for the purpose of assessing the application and administering funds for successful applicants. If this is not acknowledged, the application may not be considered any further. Release of details for publicity – There may be personal situations where a learner driver’s details cannot be released to the public. Consent to publicity and/or public release of personal details in the media is optional and will not affect the assessment of the application. Signature – If you are 16 years old or over (at the time of the application), you must sign the declaration. If you are under 16 years (at the time of the application), your parent/guardian must sign the form.
