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This form must be completed by the Club Safety Officer/Scrutineer authorised by the club and attached to a Club permit application form.
This declaration is made in reference to the following vehicle:
Vehicle details
Previous registration no. or permit no. (if applicable)
Year manufactured
Make
Model
Body type
Engine number
Colour
Issue date
Issue date
Declaration
I declare that the vehicle described above is eligible to be issued with a club permit, is safe for on-road use, and meets the requirements for the category of vehicle below
for which I have indicated below.
Name
Signature
Date
This declaration must be provided to VicRoads within 30 days of the Declaration date.
Web: vicroads.vic.gov.au
VRPIN02927 01.15 102798 Authorised and published by VicRoads, 60 Denmark Street, Kew, Victoria, 3101.