PART A DISQUALIFICATION – – Details of Court if disqualification has not yet been imposed. Next Court Date: Court Location: Type of Offence: Blood Alcohol reading: Date of Offence: Details of Disqualification if disqualification already imposed by a Period of disqualification imposed: Date of Court conviction: Court location where conviction ordered: Any other penalty imposed or order made: Date any fine was, or is to be, paid: Date the disqualification took, or will take, effect: PART B - DISQUALIFICATION BY REGISTRAR OF VEHICLES Disqualification type: Speeding Breathalyser Demerit Points Date Notice of Disqualification/Suspension Issued: (Is this the same as date of offence?) Date Disqualification /Suspension is to commence: Period of disqualification / suspension: months/years Have you received your Notice of Disqualification/Suspension from the Registrar of Vehicles? Yes (copy attached) No You may be subject to the Mandatory Alcohol Interlock Program. Please contact 1300 851 225 or for further information go to:
PART A – DISQUALIFICATION – Details of Court if disqualification has not yet been imposed. Next Court Date: Court Location: Type of Offence: Blood Alcohol reading: Date of Offence: Details of Disqualification if disqualification already imposed by a Period of disqualification imposed: Date of Court conviction: Court location where conviction ordered: Any other penalty imposed or order made: Date any fine was, or is to be, paid: Date the disqualification took, or will take, effect: PART B - DISQUALIFICATION BY REGISTRAR OF VEHICLES Disqualification type: Speeding Breathalyser Demerit Points Date Notice of Disqualification/Suspension Issued: (Is this the same as date of offence?) Date Disqualification /Suspension is to commence: Period of disqualification / suspension: months/years Have you received your Notice of Disqualification/Suspension from the Registrar of Vehicles? Yes (copy attached) No You may be subject to the Mandatory Alcohol Interlock Program. Please contact 1300 851 225 or for further information go to: