APPLICATION FOR AN EXTENSION TO PAY

NAME:  ………………………………………………………………………………

DATE OF BIRTH: ………………………………………………………………….

LICENCE NUMBER: ………………………………………………………………

STATE WHERE LICENCE HELD ……………………………………………….

I agree to pay the sum of $………………………………………..per fortnight/week

First payment due on or before ……………………………………………………… 

and I understand that if I fail to comply with this agreement, further action will be taken to recover the outstanding amount immediately and no further extensions will be entered into.

NOTE:

If you require further information, please contact this office on:

(02) 6207 1728 

…………………………………..
Signature of Applicant

Date:

…………………………….
Deputy Registrar of the
     Magistrates Court