First Name (as it appears on your driver licence)

Last Name (as it appears on your driver licence)

Driver Licence No

State issued

State class

Date of birth

HVCBA Learner Log Book number

Telephone

Email

Staff Select Staff

It is mandatory that a video camera is used in the cabin of vehicles to capture the on-road components of the Final Competency Assessment (FCA) or Competency Test (CT) as per the HVCBA Accreditation Agreement between Transport for NSW and Registered Training Organisations. This surveillance will be conducted in accordance with the Surveillance Devices Act, Workplace Surveillance Act and Privacy and Personal Information Protection Act. Do you provide consent for this assessment to be recorded?

• I consent for my FCA/CT to be recorded on video
• I do not consent for my FCA/CT to be recorded on video. I understand that my FCA/CT will not be conducted.

Consent to Information sharing

• I acknowledge and agree that

and Transport for NSW may share the following information with each other: my name, address, date of birth and licence details in order to confirm my identity and eligibility for HVCBA training and licencing. Where relevant Transport for NSW will share that information with driver licencing authorities in other states and territories within Australia.

• I acknowledge and agree that my email address may be provided to Transport for NSW for purposes of providing me with a customer satisfaction survey.
• I acknowledge and agree that during the training course or assessment, a Transport for NSW officer or a Representative of Transport for NSW may attend to conduct an Audit, Quality Assurance Check or RTO Location Visit. This may involve:

Transport for NSW Officer:

• Conducting the assessment
• Accompanying the Assessor and myself in the vehicle during an assessment
• Completing an audit of the assessment
• Completing a Quality Assurance Check of the training course or assessment
• Asking me specific questions or requesting demonstration of completed training course criteria and process

OR;

An RTO Representative:

• Conducting the assessment
• Completing the RTO location visit of the training course or assessment
• Asking me specific questions or requesting demonstration of completed training course criteria and process

Personal Information Collection Notice: our Privacy Statement explains why we are collecting your Personal Information. Transport for NSW is committed to protecting your privacy and ensuring your personal and health information is managed according to law. Find out why we collect your personal information and how we use and manage it by reading our privacy statement at www.transport. nsw.gov.au/privacy-statement or phone 13 22 13 to request a copy.