MEDICAL SELF-DECLARATION

Applicant information and completion instructions

MEDICAL DECLARATION REQUIREMENTS
Limited class riders applying for an Open Licence: complete a medical self-declaration annually.
All other classes: complete a medical self-declaration every two years.
Any “Yes” answer: a supporting doctor’s certificate is required if any condition in Section 2 is answered “Yes”.

HOW TO COMPLETE AND RETURN THIS FORM
1. Complete Sections 1, 2 and 3 clearly.
2. If you answer “Yes” to any condition, take this form to a doctor. The doctor must complete Sections 4 and 5.
3. Where a doctor’s assessment is required, the doctor retains Sections 1–4. Return Section 5 to the NZJSBA Licence Officer.
4. If no doctor’s assessment is required, submit Sections 1–3 with your licence application.

SECTION 1 | APPLICANT DETAILS