Personal Details of Applicant

This section of the Form is to be completed by the Applicant

Title:

Family Name:

Given Name:

Preferred Name:

Previous Name(s): (include ALL other names, i.e maiden name, changes by deed poll, alias names)

Family Name:

Given Name:

Family Name:

Given Name:

Family Name:

Given Name:

Gender:

Date Of Birth:

Town Of Birth:

State Of Birth:

Country Of Birth:

Passport Number:

Country of Issue:

Driver's License Number:

State/Territory of Issue:

Are you (or do you identify as) Aboriginal or Torres Strait Islander ?:

Details of Applicant

APPLICANT’S ROLE INVOLVES: (Please indicate all relevant categories – can be more than one)

Contact Details of Applicant

Current Residential Address

Suburb/Town

State

Postcode

Period of Residence:

From

To

Telephone (H):

Telephone (W):

Telephone (M):

Email Address

Current Postal Address (if different from above):

Suburb/Town

State

Postcode

• Please record all of you previous permanent residential addresses over the last five years in the space provided below (including overseas addresses). If there is insufficient space, please list them on a separate piece of paper and attach it to this document.
• If you have been a citizen of permanent resident of country/countries other than Australia since turning 18 years of age you may be asked to provide further information or sign a statutory declaration about your criminal history during this period.

Previous Residential Address (1)

Suburb

State

Postcode

Period of Residence:

From

To

Previous Residential Address (2)

Suburb

State

Postcode

Period of Residence:

From

To

Consent to Obtain Personal Information

I hereby:

1. Certify that I have fully completed this Form, and the personal information I have provided in it relates to me, contains my full name and all names previously used by me, and is correct;
2. Consent to ReadyCheack (Telads Australia Pty Ltd) disclosing personal information about me from this Form to the Australian Criminal Intelligence Commission (ACIC) and/or to Australian police services;
3. Consent to:
   
   1. the ReadyCheck (Telads Australia Pty Ltd) disclosing personal information about me to the Australian police services;
   2. the Australian police services disclosing from their records details of convictions and outstanding charges, including findings of guilt or the acceptance of a plea of guilty by a court, that can be disclosed in accordance with the laws of the Commonwealth, States and Territories and, in the absence of any laws governing the disclosure release of this information, disclosing in accordance with the policies of the police service concerned.

Date

Identification Confirmation

Please attach copies with the application

Category A Commencement of Identity Documents – ( one of these documents is required)

Category B Primary Use in the community document – (one of these documents is required)

Category C Secondary Use in the Community Documents – (2 of these required)

Submit Identification (please ensure front and back of any ID are copied where required at least 2mb per file)