Approved Inspection Station (AIS) Scheme Mobile AIS Motor Vehicle ...

Approved Inspection Station (AIS) Scheme
Mobile AIS Motor Vehicle Application
Transport Operations (Road Use Management) Act 1995
Evidence of Identity (EOI) Requirements
EOI is required at the time of making this application. Refer to the Evidence of Identity (EOI) Requirements for Individuals and
Organisations (form F4362).
Ensure you have read and understood the following documents prior to completing this application:
The Business Rules for Approved Inspection Stations
The mobile AIS motor vehicle information sheet
Visit www.tmr.qld.gov.au to download copies of the above.
This application is for:
A new mobile AIS motor vehicle (complete sections 1, 4, 5 and 6)
A replacement mobile AIS motor vehicle (complete sections 1, 2, 4, 5 and 6)
The removal of a mobile AIS motor vehicle (complete sections 1, 2 and 6)
Change of registration number of an existing mobile AIS motor vehicle (complete sections 1, 3 and 6)
1. Fixed AIS premises details
AIS number
Company or Individual name
Registered business name (if applicable)
Telephone number
Mobile number
Email address
Street address (in full)
Postal address (in full) (if same as street address write ‘As above’)
Postcode
Postcode
2. Delete mobile AIS motor vehicle
Registration number
Vehicle Identification Number (VIN)
3. Change of existing mobile AIS motor vehicle registration number
Registration number New registration number Vehicle Identification Number (VIN)
4. New mobile AIS motor vehicle details
Registration number
Make Model VIN/Chassis number
Mobile AIS motor vehicle equipment
The following equipment must be available in the mobile AIS motor vehicle before approval can be granted. It is also a condition
of approval that this equipment be kept and maintained in a serviceable condition at all times
Equipment
Manufacturer Model Serial number
Headlamp testing equipment
Brake testing equipment
Jacks, stands
5. Criminal history
Applicants must pay a fee at their nearest Department of Transport and Main Roads Customer Service Centre who carry out the
Police criminal history check (CHC) on their behalf (a Police Certificate supplied by the applicant is not acceptable). This is a
legislated requirement under Transport Operations (Road Use Management) Act 1995.
City/Town of birth State of birth Country of birth
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6. Certification
I certify that the above particulars are true and correct.
Proprietor’s/Company Director’s name Proprietor’s/Company Director’s signature Date
/ /
Privacy Statement: The Department of Transport and Main Roads (the department) is collecting the information on this form for the purposes of managing the Approved Inspection
Station scheme. This information is authorised or required by the Transport Operations (Road Use Management) Act 1995. The department or its agents usually gives some or all of
this information to vehicle insurers, statutory entities, lawyers, insolvency entities, persons involved in vehicle accidents/incidents or vehicle manufacturers or their employees or agents
and to or through interstate registration authorities. Your personal details will not be disclosed to any other third party without your consent unless required or authorised by law.
Office use only
This section only applies for new and replacement Mobile AIS motor vehicles:
If this application is for a replacement mobile AIS motor vehicle, has the Proprietor/Director attached a letter confirming
the mobile AIS motor vehicle being replaced has been decommissioned? Yes No
Are the mobile AIS motor vehicle particulars of this form correct?
Does the proposed mobile AIS motor vehicle have the mandatory equipment?
Is the equipment free of defects and in a serviceable condition?
Is the mobile AIS motor vehicle in a satisfactory condition?
Is a copy of the mobile AIS motor vehicle certificate of registration attached?
Is the mobile AIS motor vehicle registered in the Company/Business/Proprietor’s name?
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Is all inspection equipment suitably restrained in the mobile AIS motor vehicle? Yes No
Photo/s of mobile AIS motor vehicle attached?
Yes
No
Has the fee for a Criminal History Check (CHC) been paid? Yes Receipt Number
No
Has the fee for the mobile AIS motor vehicle application been paid? Yes Receipt Number
No
(Application fee not applicable when being submitted with a fixed AIS application)
Note: Any applications to ‘Delete mobile AIS motor vehicle’ or ‘Change of existing mobile AIS motor vehicle registration
number’ are emailed directly to - AIS@tmr.qld.gov.au
Approval recommended
Is approval recommended for the mobile AIS motor vehicle?
Yes
No Reason for not recommending
Transport Inspector’s name
Authority Number
District/Location
Transport Inspector’s signature
Date
/ /
Approval recommendation endorsement
Is approval recommended for the mobile AIS motor vehicle?
Yes
No Reason for not recommending
Senior Transport Inspector’s name
Authority Number
District/Location
Senior Transport Inspector’s signature
Date
/ /
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Corporate Forms Area
Form F4043 ES
V01 Mar 2013