APPLICATION FORM FOR DIGITAL TACHOGRAPH DRIVER CARD Use the checklists belw t make sure that yur applicatin is cmplete befre yu return it. Have yu cnsidered applying fr yur driver card nline? It s quicker and yu can save 15. See www.rsa.ie fr full details. FOR FIRST-TIME APPLICATIONS Please tick ü t cnfirm that yur applicatin is cmplete. Cmplete sectins 1, 2, 3, 4, 6, 7 and 9 in BLOCK capitals and in black ink. Remember t sign the Declaratin at sectin 7. Clear phtcpy f frnt and back f valid driving licence. Clear phtcpy f either a valid passprt r birth certificate. 60 payment. Enter yur credit r debit card details in sectin 9 f this frm. Cash, pstal rders, cheques r bank drafts are nt accepted methds f payment. Passprt-size phtgraph (witnessed and signed n back by Garda) see sectins 6 and 7. The pht shuld have a plain white r grey backgrund. If yu are the hlder f a nn-irish EU driving licence, submit prf f residence see Prf f residence n page 2. FOR RENEWAL OF YOUR DRIVER CARD Please tick ü t cnfirm that yur applicatin is cmplete. Cmplete sectins 1, 2, 3, 4, 7 and 9 in BLOCK capitals and in black ink. Remember t sign the Declaratin at sectin 7. If yu want t change yur phtgraph, submit a new passprt-size phtgraph (signed n the back by a Garda) and have the Garda cmplete sectin 6 f this applicatin frm. The pht shuld have a plain white r grey backgrund. 60 payment. Enter yur credit r debit card details in sectin 9 f this frm. Cash, pstal rders, cheques r bank drafts are nt accepted methds f payment. If yu are the hlder f a nn-irish EU driving licence, yu need t submit a phtcpy f yur valid driving licence and prf f residence see Prf f residence n page 2. FOR REPLACEMENT OF YOUR DRIVER CARD Please tick ü t cnfirm that yur applicatin is cmplete. Cmplete sectins 1, 2, 3, 4, 5, 7 and 9 in BLOCK capitals and in black ink. Remember t sign the Declaratin at sectin 7. If yu are the hlder f a nn-irish EU driving licence, yu need t submit a phtcpy f yur valid driving licence. 60 payment. Enter yur credit r debit card details in sectin 9 f this frm. Cash, pstal rders, cheques r bank drafts are nt accepted methds f payment. If yur existing card was lst r stlen, please prvide Garda reprt referenced in sectin 5 (A). If yur existing card was damaged r malfunctining, please attach the card and supply details in sectin 5 (B). FOR EXCHANGING AN EXISTING VALID DRIVER CARD Please tick ü t cnfirm that yur applicatin is cmplete. Cmplete sectins 1, 2, 3, 4, 6, 7, 8 and 9 in BLOCK capitals and in black ink. Remember t sign the Declaratin at sectin 7. Clear phtcpy f frnt and back f valid driving licence. Clear phtcpy f either a valid passprt r birth certificate. 60 payment. Enter yur credit r debit card details in sectin 9 f this frm. Cash, pstal rders, cheques r bank drafts are nt accepted methds f payment. Passprt-size phtgraph (signed n back by Garda) see sectins 6 and 7. The pht shuld have a plain white r grey backgrund. If yu are the hlder f a nn-irish EU driving licence, submit prf f residence see Prf f residence n page 2. See page 2 fr mre infrmatin abut yur applicatin and fr details f where t send it. Rad Safety Authrity Teach Chluain Fearta, Sráid Bhríde, Baile Lcha Riach, C. Gaillimhe Clnfert Huse, Bride Street, Lughrea, C. Galway telephne: (091) 872600 fax: (091) 872660 email: digitaltach@rsa.ie website: www.rsa.ie
APPLICATION FORM fr DIGITAL TACHOGRAPH DRIVER CARD page 2 f 8 Prf f residence Yu need t prvide prf f residence in the fllwing cases: Yu are the hlder f an EU driving licence ther than an Irish ne; r Yu are applying fr renewal f an existing Irish Driver Card and yu currently hld an EU driving licence ther than an Irish ne. Prf f residence can be a phtcpy f: A PPSN letter issued t yu at yur current address by the Department f Scial Prtectin and dated within three mnths f yur applicatin; r A utility bill (electricity, gas r phne) r a bank statement issued t yu at yur current address and dated within three mnths f yur applicatin. Supplying a phtgraph If yu are applying fr yur first Digital Tachgraph Driver Card, yu must prvide a passprt-size phtgraph signed and witnessed by a Garda. The Garda must als witness yur signature see sectins 6 and 7 f this frm. The Garda must stamp the frm with the statin stamp and this must be dated within three mnths f yur applicatin. The pht shuld have a plain white r grey backgrund. When yu are renewing r replacing an existing Driver Card, yu dn t have t supply a new phtgraph, but yu can if yu want t. The phtgraph must be passprt-size, must have a plain white r grey backgrund, and must be witnessed and signed n the back by a Garda see sectins 6 and 7 f this frm. The new phtgraph yu prvide will replace the ne held n yur file and shwn n yur Driver Card. Payment When the applicatin is submitted by pst, the fee fr a Digital Tachgraph Driver Card is 60. Please cmplete the credit r debit card payment instructin (see sectin 9 f this frm). Cash, cheques and pstal rders are nt acceptable methds f payment. When the applicatin is submitted nline, the fee fr a Digital Tachgraph Driver Card is 45. Fr mre infrmatin abut making yur applicatin nline, see www.rsa.ie. Prcessing Yu will nt be issued with a receipt fr this applicatin, but if yur applicatin is successful, yu shuld receive yur Digital Tachgraph Driver Card within tw t three weeks. If yur applicatin is incmplete r invalid, it will be returned t yu immediately. Please ensure that yu allw adequate time fr yur applicatin t be prcessed. If yu apply nline, yu will receive an email t acknwledge receipt f the 45 fee and t cnfirm that yur applicatin is being prcessed. Nte that nline applicatins have a faster turnarund time. Data Prtectin Please nte that all f the infrmatin requested n this frm is necessary fr the purpses f prcessing yur applicatin fr a digital tachgraph card. If yu fail t answer any f the questins set ut in the applicatin frm, it will nt be pssible t prcess yur applicatin fr a card. The details set ut in yur applicatin frm will be prcessed by the RSA and/r its service prviders slely fr the purpses f prcessing yur applicatin and, where yur applicatin is successful, fr ur nging dealings with yu in respect f yur digital tachgraph card. Yur details may als be prcessed fr statistical purpses. These statistics are used in such a way that individual applicants cannt be identified. The RSA will prcess yur details in accrdance with its bligatins under the Data Prtectin Acts 1988 and 2003. This includes taking all reasnable steps (including apprpriate technical and rganisatinal security measures) t prtect persnal data. The RSA may disclse persnal data t its agents, cntractrs and service prviders t the extent reasnably required fr the purpses described abve where we chse t have certain services prvided by third parties. Where third parties are used, we d s in accrdance with applicable law and take reasnable precautins regarding the practices emplyed by the service prvider t prtect persnal infrmatin. In additin t third party service prviders, we may disclse persnal data t An Garda Síchána, ther rad transprt authrities and transprt enfrcement agencies in ther EU member states r AETR states where permitted r required by law. Yu have the right, subject t certain exemptins, t btain a cpy f any persnal data which the RSA hlds abut yu and t crrect any inaccuracies in such data. If yu wish t avail f any f these rights, please cntact us at the address belw. Yur request will be dealt with as sn as pssible and in any event n lnger than 40 days after yur request. The RSA may ccasinally update this ntice. We encurage yu t peridically review the Data Prtectin ntice t stay infrmed abut hw we handle the persnal data we cllect in relatin t applicatins fr digital tachgraph cards. Queries? If yu have any queries abut cmpleting this frm, please cntact the Authrity: Telephne: (091) 872600 Email: digitaltach@rsa.ie Website: www.rsa.ie Cmpleted applicatin Send the cmpleted applicatin frm t: Rad Safety Authrity Clnfert Huse Bride Street Lughrea C. Galway. Remember t enclse all relevant dcuments (see the checklists n page 1). Rad Safety Authrity Teach Chluain Fearta, Sráid Bhríde, Baile Lcha Riach, C. Gaillimhe Clnfert Huse, Bride Street, Lughrea, C. Galway telephne: (091) 872600 fax: (091) 872660 email: digitaltach@rsa.ie website: www.rsa.ie
APPLICATION FORM fr DIGITAL TACHOGRAPH DRIVER CARD page 3 f 8 1. TYPE OF APPLICATION (Please tick ü as apprpriate) First-time applicatin Replacement card Exchange card Renewal card Date current card expires: (This is at pint 4b f yur Driver Card) Day Mnth Year 2. DETAILS OF APPLICANT Surname First name Current address Date f birth PPSN Day Mnth Year Place f birth (cuntry) PPSN: Persnal Public Service Number (available frm the Department f Scial Prtectin) Daytime phne number Mbile phne number Email address The RSA has my permissin t use my mbile phne number t cntact me. yes n Rad Safety Authrity Teach Chluain Fearta, Sráid Bhríde, Baile Lcha Riach, C. Gaillimhe Clnfert Huse, Bride Street, Lughrea, C. Galway telephne: (091) 872600 fax: (091) 872660 email: digitaltach@rsa.ie website: www.rsa.ie
APPLICATION FORM fr DIGITAL TACHOGRAPH DRIVER CARD page 4 f 8 3. DETAILS OF DRIVING LICENCE Driving licence Irish Other EU Driving licence number OR Admin. number n plastic card driving licence This is at pint 5 f yur driving licence OR at pint 4d f yur plastic card driving licence Cuntry f issue Expiry date f licence Day Mnth Year 4. OTHER DIGITAL TACHOGRAPH CARD DETAILS Indicate in this sectin whether yu are the hlder f any ther Digital Tachgraph Card(s), and if yu are, prvide details. Driver Card yes n Issuing Authrity (RSA r Authrity f ther Member State) Cmpany Card(s) yes n Cmpany Name Wrkshp Card(s) yes n Wrkshp Name Cntrl Card yes n Issuing Authrity Rad Safety Authrity Teach Chluain Fearta, Sráid Bhríde, Baile Lcha Riach, C. Gaillimhe Clnfert Huse, Bride Street, Lughrea, C. Galway telephne: (091) 872600 fax: (091) 872660 email: digitaltach@rsa.ie website: www.rsa.ie
APPLICATION FORM fr DIGITAL TACHOGRAPH DRIVER CARD page 5 f 8 5. FOR REPLACEMENT CARD ONLY Cmplete this sectin if yu already hld an Irish Digital Tachgraph Driver Card and wish t replace yur card. Please tick ü t indicate why yu require a replacement card. Existing card was lst see (A) belw Existing card was stlen see (A) belw Existing card was damaged see (B) n page 6 belw Existing card was cnfiscated see (B) n page 6 belw Existing card was malfunctining see (B) n page 6 belw Emplyment status Please indicate yur emplyment status. Self-emplyed If yu are an emplyee, please give emplyer's name and address: Emplyee (A) If yur existing card was lst r stlen, please prvide the details belw. Surname First name Driving licence number OR Admin. number n plastic card driving licence Where lst r stlen This is at pint 5 f yur driving licence OR at pint 4d f yur plastic card driving licence When lst r stlen Lcality Day Mnth Year When did yu last use the card (apprximate date)? Day Mnth Year This lss has been recrded at Garda statin Name f Garda Signature f Garda Garda number Garda Reprt number Statin stamp Phne Date reprted Day Mnth Year Rad Safety Authrity Teach Chluain Fearta, Sráid Bhríde, Baile Lcha Riach, C. Gaillimhe Clnfert Huse, Bride Street, Lughrea, C. Galway telephne: (091) 872600 fax: (091) 872660 email: digitaltach@rsa.ie website: www.rsa.ie
APPLICATION FORM fr DIGITAL TACHOGRAPH DRIVER CARD page 6 f 8 5. FOR REPLACEMENT CARD ONLY, cntinued (B) If yur existing card was damaged r malfunctining, please attach card and supply details belw. If yur existing card was cnfiscated by an enfrcement authrity, please prvide the reasn why it was cnfiscated. Rad Safety Authrity Teach Chluain Fearta, Sráid Bhríde, Baile Lcha Riach, C. Gaillimhe Clnfert Huse, Bride Street, Lughrea, C. Galway telephne: (091) 872600 fax: (091) 872660 email: digitaltach@rsa.ie website: www.rsa.ie
APPLICATION FORM fr DIGITAL TACHOGRAPH DRIVER CARD page 7 f 8 6. GARDA WITNESS FOR PHOTOGRAPH Garda certificatin I certify that the phtgraph (n the back f which I have signed my name) supplied with this applicatin is a true likeness f the applicant wh has signed the declaratin at sectin 7 in my presence. Date Day Mnth Year Name f Garda Signature f Garda Rank Garda number Garda statin Phne Statin stamp 7. DECLARATION I hereby apply fr a Digital Tachgraph Driver Card and I declare that the address indicated in Sectin 2 abve is my place f nrmal residence and that the dcuments relate t me. I am aware that if I am disqualified frm driving r my driving licence has been revked fr any reasn I am nt entitled t drive. I am als aware that a persn wh btains r attempts t btain a Driver Card by means f a fraudulent r deceptive statement r by prducing a frged dcument cmmits an ffence and is liable t be prsecuted. Signed Sign in presence f Garda and keep yur signature entirely within the bx Write in black ink nly This signature will be affixed t yur card. If yu d nt sign whlly within the bx, yur applicatin may be returned t yu. Place Pht here Plain white r grey backgrund nly Witnessed and signed n back by Garda Day Mnth Year Please remember t sign yur applicatin frm in the bx abve. Rad Safety Authrity Teach Chluain Fearta, Sráid Bhríde, Baile Lcha Riach, C. Gaillimhe Clnfert Huse, Bride Street, Lughrea, C. Galway telephne: (091) 872600 fax: (091) 872660 email: digitaltach@rsa.ie website: www.rsa.ie
APPLICATION FORM fr DIGITAL TACHOGRAPH DRIVER CARD page 8 f 8 8. FOR EXCHANGE CARD ONLY Cmplete this sectin if yu already hld a valid Digital Tachgraph Driver Card and wish t exchange yur card. Nte: Yu will need t cme t the RSA ffice in Lughrea, C. Galway t exchange yur card when the new card is manufactured. Befre an exchange takes place, the infrmatin n the riginal Driver Card must be dwnladed. If it is nt dwnladed, yu will nt have a recrd f yur previus driving, wrk and break/rest activities, which may be sught by enfrcement fficers. Details f riginal Driver Card Cuntry f issue Name f issuing authrity Driver Card number This is at pint 5b f yur Driver Card. Date current card expires Day Mnth Year This is at pint 4b f yur Driver Card. Please tick ü t indicate why yu wish t exchange yur card. Change f name Change f phtgraph Change f driving licence number Exchange a freign Digital Tachgraph Driver Card fr an Irish Digital Tachgraph Driver Card 9. PAYMENT Have yu cnsidered applying fr yur Driver Card nline? It s secure, has a quicker turnarund time, yu will be sent a cnfirmatin email, and yu can save 15 per card. See www.rsa.ie fr full details. Please debit my VISA/Mastercard/Visa debit card with the amunt f 60. Cash, pstal rders, cheques r bank drafts are nt accepted methds f payment. Cardhlder name Card number Expiry date CVV2 number 3-digit number n back f the card Rad Safety Authrity Teach Chluain Fearta, Sráid Bhríde, Baile Lcha Riach, C. Gaillimhe Clnfert Huse, Bride Street, Lughrea, C. Galway telephne: (091) 872600 fax: (091) 872660 email: digitaltach@rsa.ie website: www.rsa.ie