Learner Driver Application Form
HEAD TENANT / HOUSEHOLD DETAILS
First Name
*
Last Name
*
Address
*
DOB
*
-
Day
-
Month
Year
Date
Age
*
Gender
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number of 10 characters.
Format: 0000000000.
Eligibility Criteria Note: All criteria must be met to be eligible for an Education Scholarship
*
I have been a Pacific Link tenant or household member for more than 6 months
I am an Australian citizen or permanent resident
My rent payments and non-rent payments are up to date
Are you of Aboriginal or Torres Strait Islander origin?
Yes
No
Neither
Do you speak a language other than English at home?
Yes
No
If Yes please specify
Do you have a disability or ongoing medical condition?
Yes
No
If Yes please specify
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APPLICANT / LEARNER DRIVER DETAILS
Full Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Age
*
Gender
*
Phone Number
*
Please enter a valid phone number.
Format: 0000000000.
Email
*
example@example.com
Applicant's Licence Details
Licence Number
*
Expiry Date
*
Please upload a copy ofyour Learner Driver Licence
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Is the applicant of Aboriginal or Torres Strait Islander origin?
Yes
No
Does the applicant have a disability or ongoing medical condition?
Yes
no
Prefer not to say
Comments
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APPLICATION INFORMATION
Please tell us in your own words what the learner driver program would mean to you.
*
What is your current employment status?
*
Full-time employment (at least 38 hrs per week)
Part-time employment (fewer than 38 hrs per week)
Self-employed
Casual worker (at least 38 hrs per week)
Casual worker (fewer than 38 hrs per week)
Student
Unemployed i.e. actively looking for work
Unemployed due to an injury, illness or disability
Other
Do you agree that you are in control of your life?
*
Strongly Disagree
1
2
3
4
5
6
Strongly Agrees
7
1 is Strongly Disagree, 7 is Strongly Agrees
How many approximate hours of driving do you currently have logged?
What is your availability for Learner Driver Lessons (Days and Times)?
Do you currently have a vehicle or access to a vehicle to learn to drive in?
Yes
No
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APPLICATION DECLARATION
Full name of person making this declaration.
*
Certify that the personal information provided in this application is correct
*
Yes
I give permission for Pacific Link to collect, use and disclose personal details only forthe purpose of assessing the application and administering funds?
*
Yes
I give permission for Pacific Link to use my / my child's success story and photograph for publicity purposes in annual reports, newsletters, social media, website etc.
*
Yes
No
I would like my / my child's name changed in any publicity communications.
*
Yes, please change name
No, you can use my first name
How did you find out about the Education Scholarship program?
Website
Newsletter
Staff Member
Email
Other
Please specify
Do you give consent for PLH to use your photograph for publicity purposes?
Yes
No
Submit
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