Plate Exemption Assessment Form 

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INITIAL ENQUIRY (for new applications)	

Date Initial Enquiry Received:      /    /      

Notes: 

	

DETAILS	

NAME OF PROPRIETOR:

VEHICLE LICENCE NUMBER:                                                        EXPIRY DATE:

VEHICLE REGISTRATION NUMBER:

DATE VEHICLE FIRST REGISTERED:

MAKE:                                                                                                         MODEL:

COLOUR:                                                                 NUMBER OF PASSENGERS:

VEHICLE INSPECTION/ ASSESSMENT	

Date Vehicle Inspection/ Assessment Carried Out:      /    /      

Vehicle Accepted for Plate Exemption: Yes / No

Signed: __________________________________________________________Dated:     /    /      

Print:_____________________________________________________________

Licensing & Enforcement Manager