Step 1 of 13 - Personal Details 7% Course Information Brochures Light Rigid Licence Course Outline Medium Rigid Licence Course Outline Heavy Rigid Licence Course Outline Heavy Combination Licence Course Outline Multi Combination licence Course Outline Forklift Licence Course Outline Order Picking Forklift Course Outline Course Information Brochure* Tick here to indicate you have read and understood the Licence Course Outline for the course you are applying for. 1. Personal DetailsUSI Number (Unique Student Identifier):To obtain your USI number &/or for more information regarding USI, please log on to www.usi.gov.auFull Name* Title *Mr.Mrs.MissMs.Other Title Given Names Family Name Residential Address* Street Address Town/Suburb State Post Code Postal Address Street Address Town/Suburb State Post Code Phone Number(s)*Second contact numberThird contact numberEmail Gender*GenderMaleFemaleNot StatedIntersexDate of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Emergency Contact Name*Emergency Contact Phone*Victorian Student NumberI don't have a VSN.I have a VSN, but do not know the number.I have a VSN, and know the number.VSN Number (Victorian Student Number) Save and Continue Later 2. Course DetailsPreferred Date of CourseDay12345678910111213141516171819202122232425262728293031Month123456789101112Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920(For any changes/cancellations in Gearbox or Category, we require 7 days notice. This does not guarantee your course date. You will be notified of your actual date and time when your enrolment is confirmed.)Name of Course Undertaking:*TLILIC2014B Licence to drive Light Rigid vehicleTLILIC2015B Licence to drive Medium Rigid vehicleTLILIC2016B Licence to drive Heavy Rigid vehicleTLILIC3017B Licence to drive Heavy Combination vehicleTLILIC3018B Licence to drive Multi Combination vehicleTLILIC2001A Licence to operate a Forklift vehicleTLILIC2002A Licence to operate an Order Picking Forklift vehicleIf Truck/Bus, choose a gearbox:*AutoSynchroNon-SynchroTick box if you want to apply for:RPLCredit Transfer Save and Continue Later 3. Employment DetailsBusiness NameContact Name First Last Address Street Address Town/Suburb State Post Code Telephone Save and Continue Later 4. Language & Cultural DiversityAre you of Aboriginal or Torres Strait Islander origin?*NoYes, AboriginalYes, Torres Strait IslanderWere you born in Australia? (If not, please specify)*YesNo - please specify belowOther - place of birth*Do you speak a language other than English at home?*No, English onlyYes - please specify belowLanguage SpokenHow well do you speak English?*Very wellWellNot wellNot at all Save and Continue Later 5. DisabilityDo you consider that you have a disability, impairment or long-term condition?*(you may indicate more than one area) No Vision Hearing/Deaf Physical Medical Condition Intelectual Mental Illness Learning Acquired Brain Impairment Other Other Save and Continue Later 6. EducationWhat is your highest completed school level?*Completed Year 12Completed Year 11Completed Year 10Completed Year 9 or equivalentCompleted Year 8 or lowerDid not go to schoolIn which year did you complete that school level?*Are you still attending secondary school?*YesNoHave you successfully completed any of the following qualifications?Yes (please tick ANY applicable boxes)No (go to the Employment section)Completed Qualifications Bachelor Degree or Higher Degree Advanced Diploma or Associate Degree Diploma or Associate Diploma Certificate IV or Advanced Certificate/Technician Certificate III or Trade Certificate Certificate II Certificate I Certificates other than the above Save and Continue Later 7. EmploymentOf the following categories, which best describes your current employment status?*Full-time employeePart-time employeeSelf employed - not employing othersEmployerEmployed - unpaid worker in a family businessUnemployed - seeking full-time workUnemployed - seeking part-time workNot employed - not seeking employment Save and Continue Later 8. Study ReasonOf the following categories, which best describes your main reason for undertaking this course/traineeship/apprenticeship?*To get a jobTo start my own businessTo get a better job or promotionI wanted extra skills for my jobFor personal interest or self developmentTo develop my existing bisinessTo try for a different careerIt was a requirement of my jobTo get into another course of studyOther reasons Save and Continue Later 9. LLN AssessmentIn order to establish individual student needs and test literacy can you please write a paragraph that includes information on; complete at least one of the following paragraphs, for us to asses your reading & writing skillsYour previous learning experiences*If you have filled in the other question and this is not applicable please just write n/a or noAny areas where you needed specific assistance or support*If you have filled in the other question and this is not applicable please just write n/a or noIn order to test numeracy (FOR FORKLIFT STUDENTS ONLY) can you answer the following:700 + 325 =*12 mm x 20 mm =*200kg ÷ 10kg =*What does kg measure?*What does km/h mean?* Save and Continue Later 10. Licence Details (for Truck/Bus course participants)Please complete the following for VicRoads Eligibility and reporting requirements:Victorian Licence Number*Expiry Date*Class or classes of Licence: (eg: Car, R)*Please state how long you have held your current Australian Car Licence for?** If you have changed your licence over from Interstate/Overstate, you may be required to complete an Exemption before applying for this course.Please state any CONDITIONS on your licence (eg. Interlock)Do you have any medical condition, incl. mental/physical illness?*YesNoAny disability which may effect your efficiency in driving a vehicle?*YesNoAre you taking any prescribed medication or drugs of addiction?*YesNoIf you answered YES to any of the above questions, give details below.A medical report will need to be approved by VicRoads before booking in your course dates.Eyesight Details: EYE TEST TO BE COMPLETED AT YUGO DRIVING SCHOOL If a student fails to complete the eyesight test prior to booking course dates/times, Yugo holds no responsibility if the student fails this eyesight test on the course date, which would result in cancellation of his/her course at the expense of the student. If the student has any lazy eye/cataracts/no vision in one eye or little vision, he/she should visit our office for an eyesight test prior to course arrangements.Left Eye:Right EyeGlasses/ContactsYesNoName of Yugo PersonnelSignature of Yugo Personnel Save and Continue Later 11. Terms & ConditionsPayment is required 1 week in advance of the course starting date; or prior to booking times/dates. Refund Policy & Procedure A full refund and enrolment fees will be made if a course is cancelled by Yugo Driving School Pty Ltd for any reason. An application for refund under any other circumstance must be made in writing to Yugo Driving School Pty Ltd clearly outlining Name, address, contact details, Course details and the reason a refund is being requested. In all cases, refund are at the discretion of the General Manager/Office Manager and may be negotiated on an individual case-by-case basis. Refund conditions: Course changes/cancellations/transfer must be received 7 days prior to the commencement of the course otherwise no refund can be given. In the event the training is being paid for by an employer course fees are transferable to other employees of the company. No refunds will be given once a course has been commenced. Management has the right to charge $100 Administration fee on all course cancellations. In the event a refund is given a note with the following detail will be entered into the student file starting date of refund, amount of the refund and the reason for the refund being granted. Staff are advise of the refund policy through induction and students are advised in the Course Information outline and on the enrolment form. All Students are required to submit a USI number (Unique Student Identifier) prior to receiving a Statement Of Attainment/Qualification. Save and Continue Later 12. Declaration I herby agree to pay all fess and charges applicable to and arising from this enrolment and have and read and understand the Refund policy. I herby agree to abide by the Yugo Driving School RTO Operating Procedures I agree to provide feedback to Yugo's for continuous improvement I authorise Yugo Driving School to release information regarding my enrolment to my employer (if applicable). I consent to allowing Yugo Driving School to use photos/audio & Visual Camera Recording Footage of the assessment (for VicRoads Auditing Purposes) of me in situations relevant to training and assessment. I authorise Yugo Driving School to release information regarding my enrolment to any Government Department and other parties when Yugo Driving School is legally obliged to do so. I understand that information requested in these forms may be provided to State and Commonwealth agencies and research organisations and I consent to that occurring. All data is confidential and is not forwarded to any other party with the sole exception of the national statistical database to inform future federal funding in Vocational Training. I declare that the information supplied on this enrolment form is correct and complete. I was adequately informed of the requirements and expectations of the course as outline in the Course Information Brochure prior to enrolment. If you have any comments or suggestions for improvement for the Student information or enrolment process then please write them here.Date*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Signed:*Add digital signature.Yugo Newsletter Sign Up Sign me up to the Yugo newsletter. Subscribe to the Yugo newsletter to receive updates about our courses and course discounts that you may be entitled to. Save and Continue Later 13. Applicant Eligibility Declaration FormProvider - Yugo Driving School Pty LtdApplicant Name*Applicant Lic. No.*I declare I hold a current Australian driver licence and wish to apply for a;Licence Application*LRMRHRHCMCPlease tick the criteria of the licence category you are applying for below.Light Rigid / Medium Rigid Eligibility Criteria Held an Australian driver licence cumulatively for a period of 12 months excluding any bans Heavy Rigid Eligibility Criteria Held an Australian driver licence cumulatively for a period of 24 months excluding any bans Heavy Combination Eligibility Criteria Held an Australian driver licence cumulatively for a period of 24 months and an MR or HR for a period of 12 months excluding any bans Multi Combination Eligibility Criteria Held an Australian driver licence cumulatively for a period of 24 months and an HR or HC for a period of 12 months excluding any bans Exemption Criteria Have an exemption (hardship) or recognition (Overseas/New Zealand) which allows me to apply for a HV licence endorsement (exemption approval letter required). Additional Information I am required to have an interlock device fiited to my vehicle I have a medical condition and/or take prescribed medication My licence is cancelled, suspended or disqualified OR I have a pending cancellation, suspension or disqualification. By signing this form, I declare that the information in this form and related supportive documents is true, correct and complete. I understand that if this information is not accurate my heavy vehicle assessment result may not be valid and I will not be able to apply for a refund of the fees paid.Applicant Name:*Application Date*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Applicant Signature*Add digital signature.EmailThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle AJAX powered Gravity Forms.