or Service SA Centre, or mailed to PO Box 1, Walkerville SA 5081 Telephone Enquiries: 13 10 84 Additional Comments www.dtwww.sa.gov.auei.sa.gov.au - ABN - ABN 92 36692 3 28866 288 135 135 MR 713 www.dtei.sa.gov.au - ABN 92 3FOLD 66 288MayMay 135 bebe lodglodgeded at at any any RServiceegistration SA Centre,and Licen or smaileding Centr toe 08/06 SECTION 5: MEDICAL PRACTITIONER’S DECLARATION FOLD May be lodged at any Registration andorGPO L Seicenr viceBoxsing SA 1533,Centr Centre, eAdelaide or mailed SA 5001to PO Box 1, Walkerville SA 5081 (see also MR215A) .......................................................................................................................................................................................................................................................................................................or Service SA Centre, or mailed to POCERTIFIC Box 1, Walkerville SA 5081 ATE OF FITNESS - Under section 148 of the Motor Vehicles Act 1959 you have a legal obligation to inform the Registrar of Motor Vehicles if CERTIFICATEwww.dtTewww.sa.gov.auTelelep phonhoenei.sa.gov.aue Enqui Enquiries: -rie ABN s:- ABN1 133 92 10 10 36692 84 84 OF3 28866 288 135 FIT 135 NESS MR 713 you have reasonable cause to believe Additionalthat your Comments patient is suffering from a physical or mental illness, disabilityTe orle phone Enquiries: 13 10 84 Government (see also MR215A) www.dtei.sa.gov.au - ABN 92 3FOLD 66 288 135 MR 713 LMPR08/06 Additional Comments ....................................................................................................................................................................................................................................................................................................... MayMay bebe lodglodgeded at at any any RServiceegistration SA Centre,and Licen or smaileding Centr toe of South Australia SECTION 5: MEDICAL PRACTITIONER’S DECLARATION FOLD deficiency that is likely to endanger the public if your patient drives a motor vehicle. May be lodged at any Registration andHEAVorGPO L Seicenr viceBoxsing SA 1533,Centr Centre, eYAdelaide oVEHICLEr mailed SA 5001 to PO Box 1, Walkervi DlleRIVER SA 5081 08/06S (see also MR215A) .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. LIGCERTIFICHT VEHICLAETE (PRIVATE) OF FITNE DRIVER(see alsoSS MR215A) -S Department of Planning, Under section 148 of the Motor Vehicles....................................................................................................................................................................................................................................................................................................... Act 1959 you have a legal obligation to inform the Registrar of Motor orVehicles Service SA if Centre, or mailed to PO Box 1, Walkerville SA 5081 If you consider....................................................................................................................................................................................................................................................................................................... it prudent you may recommend that your patient undertakes a practical driving assessment. This is irrespectiveCERTIFIC of your ATECERTIFICATETeTelele p pOFhonhonee Enqui Enquiries: FITNEries: 1 133 10 10 84 84OFSS FIT - NESS Transport and Infrastructure you have reasonable cause to believe Additionalthat your Comments patient is suffering from a physical or mental illness, disabilityTe orle phone Enquiries: 13 10 84 LMPR Government (see also MR215A) patient’sAdditional age or Commentsdriver’s licence class. .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. MR 713 deficiency that is likely to endanger the....................................................................................................................................................................................................................................................................................................... public if your patient drives a motor vehicle. LICENCEHEAVY CLASSES VEHICLE C, RDATE, DRIVER LMPRR,08/06 LRS of South Australia HEAVY VEHICLELIGHT VEHICDRIVERLE (PRIVATE)S DRIVER(see also MR215A) S ....................................................................................................................................................................................................................................................................................................... CERTIFICATE OF FITNESS - Department of Planning, ....................................................................................................................................................................................................................................................................................................... If you consider....................................................................................................................................................................................................................................................................................................... it prudent you may recommend that your patient undertakes a practical driving assessment. This is irrespectiveCERTIFIC of your ATE OF FITNESS - CLIENT No. (This is your Driver’s Licence Number) Transport and Infrastructure patient’s age or driver’s licence class. ....................................................................................................................................................................................................................................................................................................... .......................................................................................................................................................................................................................................................................................................HEAVY VEHICLELICENCEHEAV DY RIVERCLASSES VEHICLES C, RDATE, DRIVER LMPRR, LRS ....................................................................................................................................................................................................................................................................................................... Driver’s Licence No: If you consider that your patient may be unfit....................................................................................................................................................................................................................................................................................................... to drive, please immediately return the completed certificate to CLIENT No. (This is your Driver’s Licence Number) ....................................................................................................................................................................................................................................................................................................... CLIENT No. (This is your Driver’s Licence Number) Locked Bag 700, Adelaide SA 5001. Information may be immediately faxed to 8402 1977. ....................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................... ......................................................................................................................................................................................................................................................................................................