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TAC L2P Learner Driver Mentor Program/
L2P Supervising Driver Application Form

L2P Supervising Driver Application Form

The personal information in this form is for the purpose of registration as a Learner Driver with the L2P program. The information will be used for this purpose only and will not be disclosed to other organisations unless required by law.

Personal Details

1. Full Name* required*

Maximum 255 characters

0/255

2. Home Address* required*

Maximum 255 characters

0/255

3. Suburb/Town* required*

Maximum 255 characters

0/255

4. Post code* required*

Maximum 255 characters

0/255

5. Email address* required*

6. Home Phone Number

Maximum 255 characters

0/255

7. Mobile* required*

Maximum 255 characters

0/255

Emergency Contact

8. Full Name* required*

Maximum 255 characters

0/255

9. Home Address* required*

Maximum 255 characters

0/255

10. Home Phone Number

Maximum 255 characters

0/255

11. Mobile Number* required*

Maximum 255 characters

0/255

Drivers License Details

12. Do you hold a full Victorian drivers licence?* required*

Yes

13. Current Drivers License Number* required*

Maximum 255 characters

0/255

14. Expiry Date* required*

Maximum 255 characters

0/255

Referees

Please provide details of two professional (work, study, or community-based) referees who you authorise for us to contact who can provide a character reference. Referees must have been known by the applicant for 12 months and must not be family members

15. Referee 1 Name* required*

Maximum 255 characters

0/255

16. Organisation* required*

Maximum 255 characters

0/255

17. Position/Relationship* required*

Maximum 255 characters

0/255

18. Phone Number* required*

Maximum 255 characters

0/255

19. Referee 2 Name* required*

Maximum 255 characters

0/255

20. Organisation* required*

Maximum 255 characters

0/255

21. Position/Relationship* required*

Maximum 255 characters

0/255

22. Phone Number* required*

Maximum 255 characters

0/255

Availability

23. Please indicate your availability for driving sessions including times* required*

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Permission to undertake further activities

Note: The personal information requested on this form is being collected by the Glenelg Shire Council for municipal purposes as specified in the Local Government Act 1989. The Council will use this information only for the specific purpose of collection or for directly related purposes. The information will not be disclosed except as required or specifically authorised by law. You may request access to any personal information that Council may have collected about you. Also, you may request correction of your personal information if you can establish that it is not accurate or complete. Such requests should be directed to Council’s Privacy Officer on telephone 03 5522 2305.

24. I agree to undertake all training relevant to the L2P program* required*

Yes

25. I agree to undertake a Working With Children Check OR I hold a current Working With Children Check* required*

Yes - I currently hold a Working With Children Check

Yes - I agree to undertake a Working With Children Check

26. I agree to undertake a VicRoads Driver History Report on my behalf OR I hold a current Driver History Report* required*

Yes - I hold a current Driver History Report

Yes - I agree to undertake a Driver History Report

27. I give permission for my information to be shared with VicRoads for reporting purposes* required*

Yes

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