This is the text only version of the Declaration form. It is simplified for use with assitive devices only. If you are able to use other versions such as PDF and MSWord, you are encouraged to download and complete the version available from the main forms site.
Note: A low-speed vehicle manufacturer or seller must provide the buyer or lessee with this document stating that he/she has read and
understood the conditions listed below prior to purchase or leasing the LSV.
Last Name, First Name, Middle Name or Company Name
Street No. and Name or Lot, Con. and Twp
City, Town or Village
Registrant Identification No. (Driver’s Licence No.)
I have read and understood the safety and operating conditions listed below.
Signature of Applicant
Note: It is the responsibility of the LSV owner/operator to ensure adherence to all LSV Pilot Program Safety and Operating conditions
and the requirements of the Highway Traffic Act. Please retain a copy of this form for your records before submitting.
Information in this form is collected under the authority of the Highway Traffic Act. If you have any questions about the collection and use of your personal
information collected on this form, please call the Supervisor, ServiceOntario at 416 235-2999 or 1 800 387-3445 or write to the Supervisor, Ministry of
Transportation, Licensing Administration Office, Main Floor, Building A, 1201 Wilson Avenue, Downsview, Ontario, M3M 1J8. Direct general inquiries to
ServiceOntario 416 235-2999 or 1 800 387-3445 or visit www.ServiceOntario.ca.
SR-LV-025E (2009/03) © Queen’s Printer for Ontario, 2009
Version française disponible