Mobility Parking Scheme Application (MPS)

Individual and Temporary Permits

For more information in conjunction with this application please see: Customer number
the Mobility Parking Scheme (MPS) brochure, or
Attachments
visit www.rta.nsw.gov.au
Important information Proof of identity
You or your representative must fill in the application form before A person applying for, renewing or replacing a MPS permit is
seeing your medical doctor. The medical information in this required to produce acceptable proof of their identity, such as a
application will be used for the administration of the MPS and driver licence. Other acceptable identification documents are
where appropriate for the Driver Licensing Scheme. The RTA has shown in List 1 and List 2 in the RTA brochure, How to prove who
a responsibility to ensure that all NSW licence holders are you are available at any RTA motor registry.
medically fit to drive. If you hold a driver licence and the RTA Applicants may show one document each from List 1 and List 2.
has not been notified of any medical condition, you will need to Alternatively, two List 2 documents, such as a current Medicare
have your doctor complete Section 3 (Medical Report) of this card or Pensioner Concession card, are acceptable. Further
application. The medical information will be used to verify your information can also be obtained from the RTA on 13 22 13 or the
medical fitness to drive. In the event that any medical practitioner RTA website at www.rta.nsw.gov.au/licensing
recommends restrictions in respect of your driver licence or
certifies that you are medically unfit to drive, this may result in
restrictions being placed on your driver licence or the suspension Fees
of your driver licence. Section 3 is not required to be completed if A fee is required for the issue of an Individual or Temporary MPS
the application is for a temporary permit issued for the first time or permit to non-pensioners. Permits are free for pensioners. Proof
where a previously held temporary permit has already expired. of the concession is required and must be validated online. For
information on current fees payable please visit
Who is eligible? www.rta.nsw,gov.au or call the RTA on 13 22 13.
To be eligible for a MPS permit, a person must be unable to walk
because of permanent or temporary loss of the use of one or both
legs or other permanent medical or physical condition, or whose Privacy statement
physical condition is detrimentally affected as a result of walking The Roads and Traffic Authority (RTA) is collecting your personal
100 metres, or who requires the use of crutches, a walking frame, and health information for your MPS application and to verify your
callipers, scooter, wheelchair, or other similar mobility aid. Permits fitness to drive and may retain and use it for driver licensing,
are also available to people who are permanently blind. motor vehicle and road transport or safety purposes.
Applicants that do not meet the eligibility criteria will not be issued The RTA is subject to the Privacy and Personal Information
a permit. Protection Act 1998 and the Health Records and Information
The minimum age for an applicant for a MPS permit is 3 years Privacy Act 2002.
old. The RTA is entitled to obtain your personal information under the
If you are required to have your doctor complete both medical Road Transport (Safety and Traffic Management) Regulation
sections of this form it may be necessary to arrange an extra 1999 and may refuse your application if you do not provide it.
consultation or an extended consultation. Please note that you are The RTA may disclose your personal information:
responsible for any fees payable to the doctor for the consultation.
to other driver licensing and vehicle registration agencies,
to assess your application or verify the information you provide
Photo requirements and,
Nearly all motor registries have disabled access and if necessary for inquiries about motor accidents.
an appointment can be made with your local motor registry for a
convenient time to have a photograph taken. Additionally, where you provide personal information concerning
Individual and Temporary MPS permits include a photo of the the registration of a vehicle we may disclose that;
permit holder, with exception of permits for people younger than to confirm any compulsory insurance is current
16 years of age. In other cases, exemptions from having a photo
will be granted only if the applicant: to anyone proposing to acquire an interest in your vehicle,
has a significant facial disfigurement, or in respect of inquiries relating to stolen or abandoned vehicles,
and
cannot meet standard RTA photo requirements of full frontal
to any joint registered operator of your vehicle.
face image due to inadequate muscular control, or
is mostly bedridden because of advanced age or terminal The RTA may disclose your health information to assess your
illness, or application or to verify it.
has a severe mental and/or physical disability that prevents Otherwise the RTA will not disclose your personal information
them from attending a motor registry without significant without your consent unless authorised by law.
inconvenience and/or embarrassment, or
Your personal and health information will be held by the RTA at
has their mobility severely restricted by medical equipment.
101 Miller Street, North Sydney NSW 2060 and you can contact
the RTA to request access or correct it.
Applying for an exemption
Applications for an exemption must be in writing, and Under clause 159 of the Road Transport (Safety and Traffic
accompanied by a completed application form with a supporting Management) Regulation 1999, penalties apply for making
letter from a medical doctor and sent to: false or misleading information.
The Manager, Customer Liaison & Data Management, RTA, P.O.
Box 3035, Parramatta, NSW 2124.
If approved, a letter of exemption will be issued for presentation at
a motor registry.

Roads and Traffic Authority ABN 64 480 155 255

www.rta.nsw.gov.au 13 22 13
Catalogue No. 45061469 RTA Form No. 1150 (09/2010) RTA ABN 64 480 155 255 Page 1 of 5
 Mobility Parking Scheme Application (MPS)
Individual and Temporary Permits

SECTION 1 5. Declaration by applicant

1. Application details ***Please read important Privacy Statement and warning
on page 1 of this form.
Type of MPS permit needed
I declare that the details in this application are true and
Individual Temporary complete and that any MPS permit issued as a result of this
application, will only be used as set out in the Conditions of
Type of Application Use. I am aware that information provided in this application is
New Renewal used for the MPS and Driver Licensing Scheme.
Replacement specify details below Signature of applicant

Lost Stolen Damaged Defaced

Confiscated Changed details Non receipt

including appearance of permit Date

Please complete application including Q7 if applicable / /

Day Month Year

Complete the declaration at 7 if you are unable to return

2. Details for Individual or Temporary MPS permit your current permit
Surname of applicant
6. Declaration by applicant's representative
***Please read important Privacy Statement and warning
Given names on page 1 of this form.
I declare that the details in this application are true and
complete and that the applicant is aware that any MPS permit
issued as a result of this application is only to be used as set
Residential address out in the Conditions of Use.
I understand that my "personal information" is being collected
as the representative of the applicant for the MPS permit.
Postcode Name of applicant's representative (please print)
Date of birth Customer no.(if known)
/ / Signature of applicant's representative
Day Month Year

Sex male female

3. Do you hold a current or suspended NSW licence? Date

No now go to 5. / /
Day Month Year
Licence number
Yes 7. Declaration for non-return of permits
This declaration must be signed if you are unable to return the
Licence class Expiry date current permit as required.
/ / I declare that the MPS permit to be returned to the RTA is not
Day Month Year available because it is lost, stolen, damaged, non receipt or
confiscated.
4. Is your licence subject to medical review by the RTA? Signature of applicant or representative
(you can check this by calling the Contact Centre on 13 22 13)
No
Yes
Date
If you ticked Yes for question 3 and No for question 4,
your doctor will need to complete Section 3 (Medical / /
Day Month Year
Report) of this application. See Important Information on
page 1 of this form.

Office use RTA Motor Registry / Agency

Proof of Identity Record
Stand alone or primary proof Secondary proof Signature of registry officer or agent

Document number Secondary proof issue or E/Date Staff number or ID Date

/ /
Day Month Year

Catalogue No. 45061469 RTA Form No. 1150 (09/2010) RTA ABN 64 480 155 255 Page 2 of 5
SECTION 2 SECTION 3

To be completed by a registered medical practitioner. Medical Report

Complete this section if the applicant has ticked Yes for Q3 in
Medical Certificate Section 1 (holds a NSW licence) and No in Q4 in Section 1(not
Please ensure that the applicant has filled in all personal subject to medical review). See Important Information shown on
details in Section 1 before signing the declaration below. page 1 of this form.
This section is required to determine if the applicant is medically
The MPS is designed to maintain the independence of people with
fit to drive.
mobility disability. Applicants that do not meet the eligibility criteria on
page 1 must not be certified as eligible for a permit. It is important that Please complete this part in conjunction with the current
only people with medical conditions that severely affect their mobility are guidelines 'Assessing Fitness to Drive' for the class of licence
certified as meeting the scheme's eligibility criteria. held (see Q3 in Section 1). The current guidelines can be found at
www.austroads.com.au
Name of applicant Where medical fitness cannot be determined, you should
refer the patient to an appropriate specialist.
The completed medical form can be returned to the patient.
Date of birth 1. History
/ / How long have you treated this patient?
Day Month Year
Years Months
I certify that I have examined the applicant shown above in
this form and the applicant's condition is: 2. Vision
One of the following clinically recognisable disabilities: VISION STANDARDS
Car, Rider and Light Rigid Drivers.
Paraplegia Chromosomal or syndromic
conditions The criteria for an unconditional licence are NOT met
Quadriplegia Neuro degenerative disorder - if the person's visual acuity in the better eye or with both
eyes together is worse than 6/12
Leg amputation Neuro muscular disorder Heavy Vehicles/Commercial Vehicles
Motor Neuron disease Blindness The criteria for an unconditional licence are NOT met
- if the person's visual acuity is worse than 6/9 in the better
Cerebral palsy eye; or
OR another non-clinically recognisable disability that meets - if the person's visual acuity is worse than 6/18 in either eye.
the MPS eligibility criteria
See 'Assessing Fitness to Drive' for more information.
(please specify)
Are glasses/lenses worn (distance)? No Yes
Visual acuity (distance) R L Together
Is the condition temporary? Yes No Uncorrected 6/______ 6/______ 6/______
If temporary, give period of disability months With glasses 6/______ 6/______ 6/______
(no more than 6 months)
Fields of vision _______ Normal Abnormal
Declaration by the registered medical practitioner
Double vision No Yes
***Please read important Privacy Statement and warning on page 1 of
this form. Poor night vision No Yes
I declare that the details in this application are true and complete. I
understand that my "personal information" is being collected for An opthalmologist or optometrist can complete this section
confirmation of the MPS Application Medical Certificate. if you wish.
I certify that today I have examined the person shown as the Name
applicant for a MPS permit and this person meets the eligibility
criteria for a MPS permit as shown on the front page of this form. Signature
Practitioner's name (please print) 3. Cardio-Vascular Condition No Yes
If No, proceed to the next question.If Yes complete the following

Business address * Acute myocardial infarct No Yes

* Angioplasty No Yes
* Angina No Yes
Postcode * Refer to Guidelines - Heavy Vehicle Licencees Only
Provider number Office telephone number Stress test -ve_______ +ve_______
Ejection Fraction %

Cardiomyopathy No Yes
Signature
CABG No Yes
Hypertension/Hypotension No Yes
Date Recurrent / persistent arrhythmia No Yes

Day
/ Month
/ Year
Cardiac pacemaker No Yes
Aneurysm (site) No Yes
Defibrillator No Yes

Catalogue No. 45061469 RTA Form No. 1150 (09/2010) RTA ABN 64 480 155 255 Page 3 of 5
4. Diabetes No Yes
Comments on any condition likely to affect driving.
If No proceed to the next question. If Yes complete the following. Append additional pages if necessary.
Controlled by: Tablets Insulin
Compliant with medication No Yes
Hypoglycaemic awareness No Yes
(date of last episode)
End organ effects No Yes

5. Musculo-Skeletal Condition
eg degenerative or painful joints, arthritis, loss of limbs/digits,
orthopaedic defect Doctor's Certification
The person whose name appears on this application was
Diagnosis examined by me today in accordance with the published
guidelines for the class of licence held or applied for and is
Condition likely to affect driving No Yes considered:
Fit to drive Unfit to drive
6. Epilepsy No Yes
If No proceed to the next question. If Yes complete the following. IF UNFIT ONLY: Please indicate if the licence holder is fit to
hold an alternative class of licence as shown below. Accordingly,
Type the licence class will then be downgraded.
Date of onset Vehicle Type Current Class
Date of last seizure Car C
Confirmed by neurologist No Yes
Motorcycle R
24 Hour EEG Normal Abnormal
Light Rigid (eg. light truck, small bus) LR
Sleep epilepsy
Confirmation by neurologist of "sleep only" Medium Rigid (eg. truck bus) MR
epilepsy during past 12 months No Yes
Heavy Rigid (eg. heavy truck, heavy bus) HR
7. Neurological Condition No Yes
Please indicate if any restriction or assessment is
If No proceed to the next question. If Yes complete the following.
recommended:
Cognitive and/or Intellectual Recommended restriction (if appropriate)
Impairments No Yes not more than (tick box) from home
Dementia No Yes
2km 5km 10km 15km 20km
Traumatic Brain Injury No Yes
30km 40km 50km 75km 100km
Loss of Limb Control No Yes
TIA/Syncope/Blackout (specify year) No Yes Daylight hours only
Modified vehicle
Strokes (specify year) No Yes
RTA Driving Test
Neuromuscular Condition: Occupational therapist driving assessment
Diagnosis Referred to appropriate specialist (nominate below)

8. Sleep Disorder No Yes

If No proceed to the next question. If Yes complete the following. Please indicate review period:-
Sleep Apnoea No Yes No further review required
Narcolepsy No Yes Normal RTA review period
Well controlled No Yes Other (specify)

Doctor's name (please print)

9. Mental Health/Nervous Disorder
eg. psychotic state, depression, schizophrenia.
Diagnosis Business address

Condition likely to affect driving No Yes

Postcode
10.Drugs likely to affect driving No Yes Signature
If Yes complete the following.
Non-prescribed drugs No Yes
Provider number (if not previously given on page 3)
Indication of alcohol abuse No Yes

Office telephone number Date

/ /
Day Month Year

Catalogue No. 45061469 RTA Form No. 1150 (09/2010) RTA ABN 64 480 155 255 Page 4 of 5
 Mobility Parking Scheme (MPS)
Conditions of use and Parking concessions
Please detach this page from your completed application form and retain for easy reference.

Displaying your permit Parking concessions

From September 2010 disability parking permits issued by the The MPS permit entitles you to park in spaces marked with a
RTA consist of two parts: an Australian Disability Parking permit symbol for people with disabilities. The permit also provides
and a Mobility Parking Scheme permit. To validate the Australian parking concessions in other spaces:
Disability Parking permit, the Mobility Parking Scheme permit When parking in metered, coupon or ticket parking areas, no
must be inserted in the plastic sleeve. charge is applied.
As a courtesy, the RTA can supply a suction cup to attach the Where parking is limited by a sign to more than 30 minutes,
permit to the vehicle window. You are not required to use this the vehicle can park for an unlimited time.
device and may use other means or devices that do not obscure Where parking is limited by a sign to 30 minutes, the vehicle
the permit details or the driver's vision. can park for 2 hours.
If you choose to use the suction cup, the manufacturer advises Where parking is limited by a sign to less than 30 minutes, the
that the suction cup's effectiveness is improved when used on a vehicle can park for a maximum of 30 minutes.
clean windscreen. Use of an alcohol wipe is recommended as
some window cleaners may leave a residue. At a 'No Parking' sign you may park up to 5 minutes, the driver
must remain within the vehicle or within 3 metres of the
Conditions of Use vehicle to drop off or pick up passengers or goods.
A MPS permit is issued subject to the following conditions - heavy
penalties may apply for failing to adhere to these conditions: All other parking rules apply.

a) The permit must only be displayed when the vehicle is being Note: Commercially owned parking facilities determine their own
used to transport the individual to whom the permit was fees and charges.
issued. It cannot be used when running errands for or visiting
a permit holder who is not travelling in the vehicle. When do the concessions apply?
The parking concessions apply when the MPS permit is displayed
b) The permit should be displayed unobscured on the left hand
on the vehicle where it is being used to transport the individual to
(passenger) side of the vehicle on either the vehicle's
whom the permit is issued.
windscreen, or on any window. If this is not practicable, it
should be placed in an area where the whole of the permit
Invalid MPS permits
may be viewed from outside the vehicle. The sides marked
'THIS SIDE UP' or 'Display this side' must face out. The permit A MPS permit becomes invalid if it expires, is revoked by the RTA
may be attached to the vehicle by any method that does not or the permit holder is deceased. Display of a MPS permit that is
obscure any of the permit details or the vision of the driver invalid can result in a heavy fine being issued.
when the vehicle is in motion.
Changes in your Medical Condition
c) The permit must be produced on direction from a police officer
or other authorised officer. If your medical condition improves and you no longer require the
use of your MPS permit, you are required to return your MPS
d) The permit is valid until the date of expiry, unless it is revoked. permit to your nearest motor registry.
e) The permit can no longer be used once it expires. It must be Hotline
renewed and a current permit displayed for any disability
parking concessions. Abuse of the MPS can be reported by phoning 1300 884 899 or
emailing [email protected]
f) The permit must be returned to a motor registry on expiry, if it
is revoked by the RTA or if the permit holder becomes
ineligible (e.g. no longer suffers from the disability that made
them eligible for the permit).
g) The permit must not be reproduced, copied, defaced, altered
or destroyed.
h) The permit is not valid if reproduced, copied, defaced or
otherwise altered or where one or more of the details on the
permit (e.g. permit number or expiry date) are illegible.
i) If the permit is used in another State or Territory, it may be
used in accordance with prevailing parking concessions.
j) The permit may be confiscated by an authorised officer and/or
revoked by the RTA for misuse or breach of any of these
Conditions of Use.
k) The permit is subject to any other such conditions that may be
imposed by the RTA.

Catalogue No. 45061469 RTA Form No. 1150 (09/2010) RTA ABN 64 480 155 255 Page 5 of 5