Microsoft word - dl04 cancel e-day licence _final_.doc
10 Sin Ming Drive Singapore 575701 Tel: 1800-CALL LTA (1800-2255 582) Fax: (65) 6553 5329
APPLICATION TO CANCEL E-DAY LICENCE FOR OFF-PEAK/WEEKEND CAR You may take 5 minutes to complete this form. You will need the following information to fill in the form:
1. The vehicle registration number; 2. The current e-Day Licence(s) usage date(s), if available (not applicable to undated e-Day Licence(s)); 3. The registered vehicle owner’s name and NRIC number (Singaporeans, Singapore PRs and Malaysians) or Passport number (Foreigners other than
Malaysians) or Company Registration number and contact number; and
4. If the registered vehicle owner is not present, the authorised applicant’s name and NRIC number (Singaporeans, Singapore PRs and Malaysians) or Passport
number (Foreigners other than Malaysians) and contact number.
IMPORTANT: Please read the INSTRUCTIONS AND NOTES overleaf before completing the application form. Application with incorrect or incomplete information wil
To Be Completed by Registered Vehicle Owner / Authorised Applicant Vehicle Registration Number : ______________________________________
*I / We wish to apply to cancel the fol owing ________________________ piece(s) of e-Day Licence(s) bought / issued for the above-mentioned vehicle. (Max 5 pieces per application)
Please tick √ the e-Day Licence(s) to be cancel ed.
(indicate the usage date if you are applying to cancel dated e-Day Licence(s))
Dated: __________________________________ (DDMMYYYY)
Dated: __________________________________ (DDMMYYYY)
Dated: __________________________________ (DDMMYYYY)
Dated: __________________________________ (DDMMYYYY)
Dated: __________________________________ (DDMMYYYY)
Declaration by *Registered Vehicle Owner / Authorised Applicant
*I / We declare that * I / we: a) have read and understood al the terms and conditions listed below and undertake to abide by them. b) *am / are the registered owner of the above-mentioned vehicle or *I / we *am / are *I am / we are duly authorised by the registered vehicle owner of the above-
mentioned vehicle to submit this application.
c) wish to apply to cancel the e-Day Licence for the usage date (if any) and vehicle registration number as stated above. d) understand that *I / we can cancel the e-Day Licence if it is stil unused. If the e-Day Licence’s usage date had been entered, *I / we must cancel the e-Day
Licence before 0700 hours of this date (i.e. up to 0659 hours of the specified usage date). Otherwise, *I / we understand that the e-Day Licence wil be considered used on the specified usage date and cannot be cancel ed.
e) understand that an undated e-Day Licence is not valid for use until its usage date has been entered by 2359 hours on the next day of the usage date. f) understand that it is a serious offence to use an Off-Peak Car / Weekend Car (OPC/WEC) on the roads during the restricted hours without a valid e-Day Licence
g) shal not hold Land Transport Authority (“LTA”) or its agents liable for any claims or disputes involving this application to cancel the usage date of the e-Day
h) agree and undertake to indemnify and to hold Land Transport Authority (“LTA”) in al respects harmless against any losses, actions, demands, suits, charges,
damages, proceedings, costs and expenses whatsoever arising from or in connection with this application to cancel the e-Day Licence(s) as specified above.
i) have ensured that the particulars furnished in this application are true and correct to the best of *my / our knowledge.
Name of *Registered Vehicle Owner / Authorised Applicant :
NRIC No.(Singaporeans, Singapore PRs & Malaysians) /
Passport No.(Foreigners other than Malaysians) of *Registered Vehicle Owner / Authorised Applicant :
Contact No. of *Registered Vehicle Owner / Authorised Applicant:
Signature of *Registered Vehicle Owner / Authorised Applicant :
The information is current at time of printing (October 2009) VRLSO-F-DL04-V00 (10PT334)
INSTRUCTIONS AND NOTES
1. Please complete the Application Form DL04 and submit it to :
a. any SingPost outlet; or b. Automobile Association of Singapore (AAS) – (1) 336 River Val ey Road, #01-00 AA Centre or (2) 2 Kung Chong Road
2. When submitting your application, please check that you have the fol owing:
a. The application form DL04, duly completed and signed. b. The original NRIC (Singaporeans, Singapore PRs and Malaysians) or Passport (Foreigners other than Malaysians) of the
registered vehicle owner/authorised applicant.
3. A system-generated Acknowledgement Page wil be issued to you once the application has been successful y processed. Please
check the Acknowledgement Page to ensure that the vehicle registration number, usage date(s) if provided, and the total refund amount is/are correct before leaving the counter.
4. Once the application for cancel ation of $20 e-Day Licence(s) is successful y processed, the registered vehicle owner wil receive a
refund equivalent to the total value of the e-Day Licence(s) via cheque by post or credited to a valid GIRO refund bank account updated by the registered vehicle owner in the Vehicle Hub of the e-Services@One.Motoring within one month.
5. Consent to the collection, use or disclosure of personal data: We may share personal y identifiable data that you have
provided in this application with other Government agencies, so as to serve you in a most efficient and effective way. We wil not share your personal y identifiable data with other entities, except where such entities have been authorised to carry out specific Government services or in accordance with legislation under the purview of the Land Transport Authority to enable us to perform our functions or duties or to comply with any order of court or in compliance with any written law, or for the purposes of taking any action against any user for breach of the conditions of use of the Authority's electronic services.
Data provided by the Authority may be used for verification and record of your personal particulars, including comparing information from other sources, and using the information to communicate with you.
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