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Owners Details

Title:

Last Name

First Name:

Phone Number :

Email:

Address

Street address

Street address line 2

City

State

Postcode

Drivers Licence Number:

Is an agent filling in this form on the owner's behalf?

Yes No

Original Manufacturers Specification

Licence Plate Number:

Make:

Model:

Body Type:

Coup

Sedan

Convertible

Utility

Station Sedan

Station Wagon

Other

Is an Australian Government compliance plate fitted?

Yes No

Estimated Date of Manufacture:

Please provide one of the following

Vehicle Identification Number Chassis Number

Tare mass (in KG):

Gross Vehicle Mass (in KG):

Engine Capacity in CC:

Number of Cylinders :

Engine Number:

Fuel type :

Petrol

Diesal

LPG/CNG

Hybrid

Natural Gas

Electric

Other

Important

You must complete all of the following sections with information related to the vehicle modifications you wish to undertake. Failure to complete the relevant sections and provide details of modifications may mean your application cannot be assessed.

Engine, transmission, differential and exhaust system

Will you undertake modifications to the engine, transmission, differential and/or exhaust system?

Yes No

Engine

Will the vehicle engine be replaced or modified?

Replaced Modified No Change to the Engine

Transmission

Original transmission type:

Automatic Manual

Will the original transmission be retained, replaced or modified?

Retained Replaced Modified

Differential

Will the differential be standard, replaced or modified?

Retained Replaced Modified

Exhaust system

Will the exhaust system be modified?

Yes No

Suspension, wheels and tyres

Will you undertake modifications to the suspension, wheels and tyres?

Yes No

Brakes

Will you undertake modifications to the brakes?

Yes No

Will the original brake pedal be modified or replaced?

Yes No

Will the original brake master cylinder be modified or replaced?

Yes No

Will the original brake booster be modified or replaced?

Yes No

Body, Chassis, seating and lighting

Will you undertake modifications to the body, chassis, seating and lighting?

Yes No

Other modifications

Describe any other modifications that are proposed but may not have been fully explained by the questions in this form.

Authorisation

I declare that I am the owner of the vehicle, or the authorised agent as specified above, and I am responsible for the information provided, and that this information is true and correct.

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Page updated 21 May 2025 07:33 pm

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About the Transport Portfolio

Acknowledgement of Country

The Department of Transport acknowledges the Traditional Custodians of the land and their connection to land, waters and community. We pay our respect to all members of Aboriginal communities and their cultures; Elders past, present and emerging.

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