Approved Inspection Station Scheme Change/ReplacementTransport Operations (Road Use Management) Act 1995

continued page over ... Page 1 of 2 TRB Forms Area Form F4638 CFD V01 Jul 2017

1. Application type – Tick relevant application types: þ

2. Add or remove approved examiner/s – for approval as a new approved examiner use form F2339.

3. Remove nominee from AIS – for approval as a nominee use form F2203

4a. Additional/replacement mobile AIS vehicle/s

4b. Remove mobile AIS vehicle/s

4c. Change of mobile AIS registration number plate/s

Approved Inspection Station (AIS) Number

A. Add or remove approved examinerB. Remove nominee from AISC. Changes to mobile AIS vehicleD. Change of business/ company name

E. Replacement AIS approvalF. Remove vehicle type inspection codeG. Multi-list AIS staffH. Surrender AIS approval

Complete sections 2 and 10 Complete sections 6 and 10

Complete sections 4 and 10Complete sections 8 and 10

Complete sections 3 and 10 Complete sections 7 and 10

Complete sections 5 and 10 Complete sections 9 and 10

Registration number Make/model VIN or Chassis Number

Registration number Make/model VIN or Chassis Number

5a. Change of AIS company name - must be the same Australian Company Number (ACN).ACN New company name

Prior to submitting your application you should have access to and review: (available at www.tmr.qld.gov.au)• the Code of Practice – Vehicle Inspection Guidelines (light vehicles)• the National Heavy Vehicle Inspection Manual (heavy vehicles)

• the Business Rules for Approved Inspection Stations• all relevant information sheets.

Given name/s Family name Approved examiner number Start date Exit date

Given name/s Family name Exit date

Does the vehicle have access to all the equipment necessary for inspecting vehicles of the type that will be inspected?Yes No This application cannot proceed.

Previous registrationnumber

New registrationnumber Make/model VIN or Chassis Number

Is a company extract showing director/s attached?Yes No This application cannot proceed.

Page 2 of 2 TRB Forms Area Form F4638 CFD V01 Jul 2017

Approved Inspection Station Scheme Change/Replacement continued... page 2 of 2

8. Multi-list AIS staff

Light vehicles up to 4.5t GVM (LV) Heavy vehicles over 4.5t up to 16t GVM (HV) Motorcycles (MC)Light vehicles COI up to 4.5t GVM (CL)*

Light trailers up to 3.5t ATM (LT) Heavy trailers over 3.5t up to 10t ATM (HT)

7. Remove AIS vehicle type inspection code/s – Tick relevant code/s: þ

9. Surrender AIS approval

10. Declaration and consent

I have decided to: (tick relevant box/es: þ)•stop carrying on business as an AIS•not to renew my AIS approval

and I have returned:•anyunusedinspectioncertificates,safetylabelsandinspectionreports•allusedinspectioncertificates,safetylabelsandinspectionreportsuptotwoyearsold.to on Date

/ /

5b. Change of AIS business name – must be the same approval holder

6. Replacement AIS approval –

New business name

AIS numbers (must be approved in the same individual/company/partnership name to be eligible for multi-listing)

Is a current Business Name Extract showing the business name holder attached?Yes No This application cannot proceed.

Tick relevant box: þLost Stolen DestroyedThe AIS approval was:

Customerservicecentre/Complianceoffice

• theinformationprovidedbyme/usinthisapplicationiscomplete,trueandcorrectineverydetail.

•verifyingtheEvidenceofIdentity(EOI)informationprovidedbyme/us,withtheissuingauthority•accessing departmental records to verify my/our suitability to become an AIS approval holder.

Privacy Statement: The Department of Transport and Main Roads is collecting the information on this form for the purposes of managing the AIS scheme. This information is authorised or required by the Transport Operations (Road Use Management) Act. The Department of Transport and Main Roads or its agents usuallygivessomeorallofthisinformationtovehicleinsurers,statutoryentities,lawyers,insolvencyentities,personsinvolvedinvehicleaccidents/incidentsorvehicle manufacturers or their employees or agents and to or through interstate registration authorities. Your personal details will not be disclosed to any other third party without your consent unless required or authorised by law.

Approval holder/nominee’s name

Approval holder/nominee’s name

Approval holder/nominee’s signature

Approval holder/nominee’s signature

Date

Date

/ /

/ /

Lodge completed applications to:

I/we declare that:

I/we consent to the Department of Transport and Main Roads:

AIS AdministratorDepartment of Transport and Main RoadsPO Box 673FORTITUDE VALLEY QLD 4006

AIS@tmr.qld.gov.au or

•my/our responsibilities as the holder/s of an AIS approval under the Transport Operations (Road Use Management) Act• it is an offence under the Transport Operations (Road Use Management) Act to provide a false or misleading statement or

document as part of this application• thatfailuretocomplywithalltherelevantlegislation,statutoryconditionsandtheBusiness Rules for Approved Inspection

Stations of my/our AIS approval may result in the suspension or cancellation of my/our AIS approval.

I/we understand that: