Purpose of Declaration

To effectively manage the on road movement of large indivisible loads the mass of any load presented for movement must be declared. This will allow transport operators and road authorities to determine the feasibility of these movements, appropriate vehicle configurations and conditions of operation. / Office Use Only
Application number

1. Consignor information

Name of Consignor

Trading name (for organisations); or Full name (for individuals)

Consignor details

Reference Number (CRN/ABN/BN) / Australian Company Number (ACN)
Business address
Contact person / Phone number
Mobile number / Fax number

2. Load information

Load details – Full description of load

Load Description
Make/Model (If applicable) / Chassis / Serial / Drawing Number
Source of Mass Information / Transport Mass (tonnes)
Equipment included in Transport Mass
Equipment removed for Transport
Load Dimensions / Length / m / Height / m / Width / m

3. Additional Information Relevant to this Declaration

4. Signature of Person Authorised by Consignor

I hereby certify that the information supplied in this declaration is true and correct, and in my authorised capacity, indemnify the Directors-General of Department of Main Roads and the Department of Transport against any claim, action or process for damage or injury which may be sustained against them by reason of the use of this declaration.

Full name / Position
Signature / Date
Warning
It is an offence under the Transport Operation (Road Use Management) Act 1995 if you state anything or give a document if you know it contains false or misleading information. The maximum penalty for this offence is $10 000.
Privacy Disclaimer
The information on this form is collected under the authority of the Transport Operations (Road Use Management) Act 1995. The Department of Transport and Main Roads requires this information for the issuance of permits. Authorised officers from the Department of Transport and Main Roads have access to this information and will not disclose your information to third parties without your consent or unless required by law.

Page 1 of 1 Document and Forms Management

Form M4130bb ES August 2006