Wajarri Drive Program Application Form

APPLICATION DECLARATION
I agree to allow the Wajarri Liaison Committee to receive a copy of this application to make a determination of my eligibility to participate in this program.
TO ACCEPT, TYPE YOUR NAME BELOW*
I agree that my typed name above can be used as a digital representation of my signature to that fact.
NAME:*
FIRST NAME: LAST NAME:
ADDRESS*
TELEPHONE:*
MOBILE:*
MOTHER'S NAME:*
FATHER'S NAME:*
MATERNAL GRAND MOTHER'S NAME:*
MATERNAL GRAND FATHER'S NAME:
PATERNAL GRAND MOTHER'S NAME:
PATERNAL GRAND FATHER'S NAME:
I REQUIRE ASSISTANCE TO:*
Please tick appropriate box.
- Complete my log book hours – 25 hours
- Complete my log book hours – 50 hours
- Obtain my C Class Driver’s License
- Obtain my Heavy Vehicle License
I understand that if I am accepted to participate in this program that I am required to give a minimum of 16 hours’ notice to the driving company representative if I am unable to attend any driving session organised for me.

I also understand that if I fail to give notice and or do not attend a driving sessions I may be removed from the program.
TO ACCEPT, TYPE YOUR NAME BELOW*
I agree that my typed name above can be used as a digital representation of my signature to that fact.
For any application enquiries please contact the office on 08 9997 3444 or email members@wajarri.com.au

APPLICATION DECLARATION