Office use only

Eyesight Test

Did the applicant wear corrective lenses during the vision test?

Name

Signature of Authorised Officer

Tester number

Date/time passed

Pass or Fail

Theory Test

Test type

KT4

KT5

Test attempts record

Tester name

Test date/time

KT No.

Score

Result

Signature of Authorised Officer
Date/Time Passed

Tester number

Practical Test

Practical Test
Test Type
Signature of Authorised Officer

Name

Tester number

Date Passed
Off-Road Competency

Off-Road Competency Tests

Off-Road Competency Test
Fail Date/Time

Assessor

On-Road Competency

On-Road Competency Tests

On-Road Competency Test
Fail Date/Time

Assessor

Evidence of Identity (Original documents only)

Primary Evidence

If 'Other' specify here

Origin (State/Country)

Document number

Expiry date

Secondary evidence sighted

Type of document

Reference number

Evidence of Residence sighted

Type of document

Signature of Authorised Officer

Name

User ID

Certificate of Competence

Name of Provider

Date of Issue

Test Location

Tester number

Certificate Number

Certificate Type

Cancelled CoC Numbers

Cancelled CoC Number

CoC number

Comments

Make notes here

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.