Your Name

Company Name

Purchase Order Number / Job Reference

Accounts Email

Do you require a CAR application? Do you require a CAR application? Yes No

Bill Payer Name

Principal Name

Contractor Name

If you already have a CAR, please provide the CAR number here:

Site Location

Work Area Start - RS/RP or House Number

Work Area End - RS/RP or House Number

Working in Carriageway? Working in Carriageway? Yes No

Footpath Affected? Footpath Affected? Yes No

Cycle Lane Affected?* Cycle Lane Affected?* Yes No

Property Access Affected? Property Access Affected? Yes No

Restricted Parking Affected? Restricted Parking Affected? Yes No

Proposed TTM Method Proposed TTM Method Shoulder Closure/Pedestrian Management Lane Closure Contraflow Stop/Go - 2 Way Stop/Go - 3 Way Stop/Go - 4+ Way Priority Give Way Mobile Semi-Static Road Closure One-Way Closure Ramp Closure Other

Aftercare/Unattended TTM Required? Aftercare/Unattended TTM Required? Not Required Shoulder Closure/Pedestrian Management Lane Closure Advance Warning Only Advance Warning with TSL Road Closure Other

Reason For Unattended TTM

Select any of the following that will used afterhours Select any of the following that will used afterhours Steel Plates Modular Road Plates Kerb Ramps Temporary backfill Temporary reinstatement Other

Will Traffex be delivering the TTM? Will Traffex be delivering the TTM? Yes No

TTM Contractor Name

24/7 Contact Name & Number

STMS Name

STMS Contact (Phone Number)

STMS NZTA ID

STMS NZTA Warrant STMS NZTA Warrant TMO STMS (A) STMS (B) STMS (C)

Description of Work Activity (brief description only - Eg. Road digout)

Works Methodology (Detailed plan of how the work will be carried out. This helps us design an effective traffic management plan that works!)

Plant required on site

Proposed Start Date

Proposed End Date

Number of Working Shifts

Shift Shift Dayshift (Monday - Friday) Nightshift (Sunday - Thursday) Weekends Public Holidays

Proposed Working Time - Start

Proposed Working Time - End

Do you require us to complete an A3 form on your behalf (charges may apply)? Do you require us to complete an A3 form on your behalf (charges may apply)? Yes No

Do you require us to complete communication letters on your behalf (charges may apply)? Do you require us to complete communication letters on your behalf (charges may apply)? Yes No

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