Fillable 23059649 (Services Australia)

Fill Online, Printable, Fillable, Blank 23059649 (Services Australia) Form

Use Fill to complete blank online SERVICES AUSTRALIA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

23059649 (Services Australia)

On average this form takes 76 minutes to complete

The 23059649 (Services Australia) form is 33 pages long and contains:

  • 5 signatures
  • 30 check-boxes
  • 270 other fields

Country of origin: AUSTRALIA
File type: PDF

Use our library of forms to quickly fill and sign your Department of Human Services forms online.

Services Australia, (previously DHS - Department of Human Services) is responsible for delivering services relating to health and welfare of Australian citizens. It processes payment of child support other services.

BROWSE SERVICES AUSTRALIA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
D22/026664 Limited Registration – DoE – Final year pre-service teacher for casual staff seeker pool
Issued 01/03/2022 Uncontrolled when printed Page 1 of 13
Application for Limited Registration
for pre-service teachers in their final year
Department of Education casual staff seeker pool
2022
This application is for use by the Department of Education’s delegate to apply for
Limited Registration on behalf of a pre-service teacher in their final year of study
for employment through the 2022 casual staff seeker pool.
Limited Registration is a category of registration that allows employers/educational venues the ability to
employ suitably qualified people, who are not registered teachers, to fill specific teaching roles when
needed.
To be eligible for the grant of Limited Registration the pre-service teacher must:
• have an offer of a teaching position in an educational venue
• have the required qualification(s) and/or expertise and skills relevant to the teaching position
offered
• have the English language skills suitable for registration as a teacher
• be a fit and proper person to be registered.
This application form may be used to cover multiple schools, a cluster of schools or an educational
region(s).
Delegate: The individual nominated by the Department of Education who has authority to make the
application on the Department’s behalf and who will act as the primary point of contact for the application,
and who has offered the pre-service teacher a teaching position in a school or schools.
Pre-service teacher: for the purposes of this application, a person in their final year of study who has
completed either 50% of a Master of Teaching or 75% of a Bachelor of Education, and who has been offered
the teaching position in a school or schools.
Instructions for completing this form
Pre-service teacher to complete:
• Section 1 of this form
• Nationally Coordinated Criminal History Check Application and Informed Consent form
• Verification of identity by an authorised third-party form.
Delegate to complete:
• Section 2 of this form.
The delegate is also required to ensure the application has been completed, signed and includes all
information before emailing it to info@trb.education.wa.edu.au.
D22/026664 Limited Registration – DoE – Final year pre-service teacher for casual staff seeker pool
Issued 01/03/2022 Uncontrolled when printed Page 2 of 13
Section 1: Pre-service teacher to complete
This section is to be completed by the pre-service teacher.
Personal details (please print clearly)
Have you previously applied for or held registration with the TRBWA (or WACOT)?
() Yes No Registration number (if known):_________________
Title Dr Mr Mrs Ms Miss Other_______________
Given name
Middle name(s)
Family name/surname
Preferred name
Gender Male Female Other/unknown
Date of birth (dd/mm/yyyy)
Other names by which I am or ever have been known including: Alias (A), name change by Marriage (M) or previous name,
changed by Change of Name Certificate by Department of Birth, Deaths and Marriages (P) (please beside each other name).
If more room is required, list on a separate sheet. Please sign and send the sheet with this application form. Additional sheet
included? Yes No
A M P
(Given name and other names)
A M P
(Given name and other names)
Address Information
Current postal address (No. Street) e.g., 1 Town Street
Country
Suburb/Town/City
State
Postcode
Is this also your current residential address? Yes No
Current Residential address (if different from postal address) (No. Street)
Country
Suburb/Town/City
State
Postcode
Date resided from (dd/mm/yyyy)
Contact Details
Preferred contact number Mobile or Landline
Mobile
Landline
Preferred email
Alternate email address
PLEASE NOTE: The TRBWA will use this email address as your registered email address for contact purposes. During the
application process it is your responsibility to inform the TRBWA of any changes to your contact details.
Place of Birth
Country of Birth
State
Suburb/Town/City
Other Information
Are you of Aboriginal and/or Torres Strait Islander descent? Yes No
D22/026664 Limited Registration – DoE – Final year pre-service teacher for casual staff seeker pool
Issued 01/03/2022 Uncontrolled when printed Page 3 of 13
Pre-service teacher’s qualification profile
The TRBWA will assess the pre-service teacher’s qualifications (partially complete and completed), expertise and skills in
relation to the teaching position offered by the Department. Please detail these in the table below. Also include copies of
all relevant documents, as detailed below, with this application.
Title of initial teacher education
program currently studying.
Institution
State, Territory
or Country of
issue
Full time
length of
course
Estimated
completion
date
Title of other qualification(s)/
certificates
Institution
State, Territory
or Country of
issue
Full time
length of
course
Date
Completed
Evidence: Please attach the following documents for each qualification listed above:
• Current initial teacher education program being studied
Provide evidence of current course enrolment and all of the units completed and that are currently being undertaken.
(Website printouts are acceptable.)
• For other Australian and New Zealand qualifications:
Copy of the final academic record (academic transcript).
• All other qualifications:
Copy of the qualification (parchment/certificate); and
Copy of the final academic record (academic transcript/Diploma Supplement).
• Skills and expertise:
For other skills and expertise in subjects that may be relevant to teaching positions offered, provide any other
evidence that you may consider relevant and also include a copy of your most recent Curriculum Vitae.
If a single document covers more than one of the evidence requirements, please only submit one copy of that document.
Where documents are in a language other than English, both the original language document and a translation
completed by the National Authority for Translators and Interpreters (NAATI) must be provided.
D22/026664 Limited Registration – DoE – Final year pre-service teacher for casual staff seeker pool
Issued 01/03/2022 Uncontrolled when printed Page 4 of 13
Pre-service teacher’s declaration as to whether they are a fit and proper
person to be a registered teacher in Western Australia
The Teacher Registration Act 2012 (Act) requires the TRBWA to have regard to certain matters to
determine whether you are a fit and proper person to be registered. Read carefully before responding.
It is an offence under the Act to provide false and misleading information to the TRBWA in order to gain
registration. You are required to respond to the following questions ().
Yes
No
1. Have you ever had registration, licensing, classification or other authority as a teacher suspended,
cancelled or withdrawn in Australia or any other country?
2. Are you subject to any conditions in practising the profession of teaching in Australia or any other
country?
3. Have you ever been refused registration, licensing or classification as a teacher in Australia or any
other country?
4. Have you ever been, or are you currently, the subject of disciplinary action in response to allegations
concerning incompetence as a teacher, misconduct as a teacher, or fitness to be a teacher, including
preliminary investigation, either informal or formal in Australia or any other country?
5. Do you have a serious medical condition, or mental or physical impairment, that adversely affects, or is
likely to affect, your ability to practise as a teacher?
If you have answered ‘Yes’ to this question, the TRBWA needs to make a determination about the
extent to which your ability to practise as a teacher is, or is likely to be, adversely affected.
For further information, please refer to the Fit and Proper Policy – Medical Conditions and
Impairments. Please complete and enclose the Medical Conditions and Impairments form.
6. Have you ever been dismissed or resigned from teaching in response to or following allegations of
misconduct in Australia or any other country?
7. In the last six months have you used any illicit drugs or engaged in any substance abuse?
8. Have you ever been convicted of any offences (including criminal and traffic) in any overseas country?
9. Do you have any outstanding criminal charges in any overseas country?
If you have answered YES to any of these questions, you must provide FULL details in a sealed envelope
marked ‘Private and Confidential’ and posted to:
Fit and Proper Assessment
Teacher Registration Board of Western Australia
PO Box 3019
EAST PERTH WA 6892
This may include:
• responses to additional questions if you answered ‘Yes’ to question 5;
• a detailed submission from you as to how the events arose, what allegations
were made, any findings against you, and what you have done since;
• a Statement of Material Facts if appropriate;
• character references (particularly where the referee knows about the events
leading to this situation);
• documentation showing an outcome of the matter.
Please provide sufficient information to assist the Board with their assessment of whether you are a fit
and proper person to be registered.
D22/026664 Limited Registration – DoE – Final year pre-service teacher for casual staff seeker pool
Issued 01/03/2022 Uncontrolled when printed Page 5 of 13
National criminal history check for the pre-service teacher
As part of the assessment by the TRBWA as to whether the pre-service teacher is a fit and proper person, consideration is given
to any criminal history they may have, pursuant to section 24(c) of the Act.
The pre-service teacher is required to consent to the TRBWA completing a national criminal history check. Consent is
provided by completing a Nationally Coordinated Criminal History Check Application and Informed Consent Form,
which is found at the end of this
application form and can also be found on the TRBWA website (trb.wa.gov.au).
Proof of identity requirements
The pre-service teacher is required to provide four identity documents with the consent for a national criminal
history check. The combined identity documents must contain the pre-service teacher’s full name, date of birth and a
photograph. If the identity documents do not include a photograph they must submit a passport-style photograph
certified by a person listed in the ‘Authorised Third Parties for the Verification of Identity’ information sheet which is
found at the end of this form. Please refer to the Nationally Coordinated Criminal History Check Application and
Informed Consent Form for a list of documents required for the national criminal history check.
Change of name
If you provide identity documents using a former name, you must provide evidence of your name change. This means providing
a change of name certificate issued by the Australian Registry of Births, Deaths and Marriages or an Australian marriage
certificate issued by a state or territory, in addition to your four identity documents. Church or celebrant-issued certificates are
not accepted.
Please note, any other name variations may require evidence to support the change of name.
Special provisions for proof of identity
There may be circumstances in which a pre-service teacher may not be able to meet the minimum proof of identity
requirements. If you are unable to provide the minimum identity requirements, as listed on the Nationally
Coordinated Criminal History Check Application and Informed Consent Form (found at the end of this application
form), please contact the TRBWA who will assess your ability to meet the requirements and determine the most
suitable method. Please email info@trb.education.wa.edu.au.
Verification of identity
As part of the process to undertake a national criminal history check, the TRBWA is also required to verify the identity of a
preservice teacher. This involves the comparison of the original photographic identification document provided as part of the
application process with a visual comparison of the preservice teacher.
Verification will be completed by an authorised third party on behalf of the TRBWA.
For the purposes of teacher registration, an authorised third party is an occupation or person as listed in the Statutory
Declaration Regulations 2018. A list of authorised third parties is available in the ‘Authorised Third Parties for the Verification of
Identity’ information sheet which can be found at the end of this form.
To verify a person’s identity, the authorised third party must:
1. sight all identity documents (including the photographic identification document) used as part of this online form
2. make a face-to-face visual comparison between the person and the original photo identification document; and
3. verify through a declaration as to the person’s identity.
The authorised third party is to be presented with all the original identity documents submitted as part of the application for
comparison. If they are unable to establish that you are the person represented in the application, additional photo
identification may be requested.
The ‘Verification of identity by an authorised third party’ declaration is found at the end of this form.
If you are unable to access an authorised third party to complete the identity verification process, please email
info@trb.education.wa.edu.au for further advice.
Please note this application will not be finalised until this process has been completed.
D22/026664 Limited Registration – DoE – Final year pre-service teacher for casual staff seeker pool
Issued 01/03/2022 Uncontrolled when printed Page 6 of 13
Pre-service teacher’s consideration as to whether they must provide an
overseas criminal history check (from a country other than Australia)
As the pre-service teacher, you are required to provide an overseas criminal history check (OCHC) from every country you
have resided in for a cumulative
1
period of 12 months or more, from 18 years of age, during the 10 years prior to making an
application for teacher registration.
Have you resided in any country other than Australia for a cumulative
1
period of 12 months or more,
from 18 years of age, during the 10 years prior to making this application? ()
If you have answered ‘No’, please proceed to the Registration Obligations section.
If you have answered ‘Yes’, please proceed to the requirements below for obtaining an overseas
criminal history check.
Yes
No
Obtaining an overseas criminal history check from fit2work
To obtain an OCHC you must apply directly to fit2work the approved provider of OCHCs for the TRBWA.
OCHCs issued by other providers will not be accepted.
You can apply for an OCHC online at: https://fit2work.com.au/PreEmployment.aspx?id=trbwa.
This link can also be accessed from the TRBWA website (trb.wa.gov.au).
You can check on the progress of your fit2work OCHC at any time, by logging onto fit2work. Once completed, the result of
your OCHC will be emailed to you and also provided directly to the TRBWA.
Please note, your fit2work OCHC application is separate to your teacher registration application. Payment for your OCHC must
be made directly to fit2work.
If you have any questions regarding your fit2work OCHC application, please contact:
fit2work
tel: 1300 525 525
email: ichc@fit2work.com.au
If fit2work does not conduct a check for the country you resided in, the TRBWA may accept a statutory declaration. Please
contact the TRBWA to request a statutory declaration.
Please do not provide your own statutory declaration or obtain one from Australia Post.
1
*Cumulative – the total time spent in each individual country in the 10 years prior to making this application for registration.
Example - If you are not currently registered, and you spent 6 months in the UK in 2015 and another 6 months in 2017, the total time spent in the
UK would be 12 months within the past 10 years. You would, therefore, be required to provide a criminal history check from the UK.
D22/026664 Limited Registration – DoE – Final year pre-service teacher for casual staff seeker pool
Issued 01/03/2022 Uncontrolled when printed Page 7 of 13
Pre-service teacher’s list of required overseas criminal history checks
Overseas criminal history checks table
In the table below, please list every country, other than Australia, you have resided for a cumulative
1
period of 12 months or more,
from 18 years of age, during the 10 years prior to making this application. For every country, please identify whether you are:
1) supplying an OCHC from fit2work with your application
2) currently in the process of obtaining an OCHC from fit2work
3) submitting a statutory declaration to the TRBWA, as an OCHC is not available from fit2work for that country
Country
(1)
I have applied for and been issued an
OCHC for this country by fit2work. A
copy of this OCHC will be provided
directly to the TRBWA by fit2work.
(2)
I am currently in the
process of obtaining
an OCHC from
fit2work for this
country. Once issued,
a copy of this OCHC
will be provided to
the TRBWA by
fit2work.
(3)
I have checked the list at
https://fit2work.com.au/Pre
Employment.aspx?id=trbwa.
and Fit2 work do not
provide an OCHC for this
country. *
Date issued
(DD/MM/YYYY)
Reference number
If Yes, tick () below
*If fit2work does not conduct checks for the country you resided in, the TRBWA may accept a statutory declaration. Please
contact the TRBWA to request a statutory declaration.
Please do not provide your own statutory declaration or obtain one from Australia Post.
NOTE: A statutory declaration has to be received in hard copy
1
*Cumulative – the total time spent in each individual country in the 10 years prior to making this application for registration.
Example - If you are not currently registered, and you spent 6 months in the UK in 2015 and another 6 months in 2017, the total time spent in the
UK would be 12 months within the past 10 years. You would, therefore, be required to provide a criminal history check from the UK.
D22/026664 Limited Registration – DoE – Final year pre-service teacher for casual staff seeker pool
Issued 01/03/2022 Uncontrolled when printed Page 8 of 13
Pre-service teacher’s registration obligations
Registration as a teacher carries with it a number of obligations. I understand it is a requirement for me to:
• maintain my teacher registration which includes the requirement to pay an annual fee by 31 March each year
• provide notice to the Board if I have a change of name, postal or email address within 30 days of these changes
occurring (noting that failure to comply with this requirement may result in a penalty fine to the maximum of $1,000).
• provide written consent to the TRBWA, upon request, to obtain a criminal history check
• comply with any conditions placed on my registration
• continue to be a fit and proper person to be registered
• provide written notice to the TRBWA, under sections 38, 39 and 40 of the Teacher Registration Act 2012 (Act):
o of any civil proceedings which result in orders to pay damages or compensation (within 30 days)
o if I am convicted of an offence which includes a statutory penalty of imprisonment (within 30 days)
o about any loss of my qualifications (within 30 days)
o if I receive a working with children interim negative notice or negative notice (within 14 days) noting that I may
commit an offence if I fail to notify the TRBWA within the time specified which could result in a penalty fine to
the maximum of $5,000.
Further information about your obligations as a registered teacher can be found on the TRBWA website.
Department of Education consent (recommended)
If you provide consent, please tick () the following:
I consent to the TRBWA disclosing to the Western Australian Department of Education the date on which the TRBWA
determines that I am a fit and proper person to be a registered teacher.
Pre-service teacher’s declaration
I, ______________________________________________________________________________________
Full name
of _____________________________________________________________________________________,
Address
sincerely declare that the information I have provided in this application is complete, true and correct, and I understand my
obligations as a registered teacher.
Signature _______________________________ Date_______________
It is an offence under the Act to provide a false or misleading statement.
Sign Here
click to sign
signature
click to edit
D22/026664 Limited Registration – DoE – Final year pre-service teacher for casual staff seeker pool
Issued 01/03/2022 Uncontrolled when printed Page 9 of 13
Section 2: Department of Education’s delegate to complete
Teaching duties and schools/regions where teaching will be undertaken.
Educational venue details
Employer
Department of Education Western Australia
School, schools, cluster or
educational regions(s) at which
teaching will be undertaken
Postal Address
151 Royal Street East Perth
6004
Delegate’s details
Primary contact person for this Application for Limited Registration. The individual nominated by the Department who has
authority to make the application on the Department’s behalf.
Delegate’s name
Delegate’s position or job title
Delegate’s email address
Delegate’s contact numbers
Work:
Mobile:
Period of registration
The pre-service teacher will be given an eighteen-month period of Limited Registration from the date the Board grants
registration.
Assessment information
The grant of Limited Registration and the relevant conditions that will limit the teaching activities will be
determined by an assessment of the subject/discipline content of the initial teaching education (ITE) program, any
specialisations, and the major and minor learning areas for secondary programs.
In general terms, the Board’s approach is as follows:
• Primary ITE programs and Early Childhood ITE programs (0-8)
Pre-service teachers in the final year of an early childhood or primary teaching program would meet the
qualifications or expertise or skills eligibility criteria to undertake relief teaching across Years K to 6 in a
primary school(s) (including kindergarten and pre-primary).
• Secondary ITE programs - Years 7 to 12
Pre-service teachers in the final year of a secondary teaching program would meet the qualifications or
expertise or skills eligibility criteria to undertake relief teaching in learning areas relevant to their major and
minor areas of study for undergraduate programs and discipline-specific curriculum for graduate programs, in
a secondary school(s).
In addition, any other previous qualifications, skills or experience relevant to other learning areas may also be
considered.
Consideration would also be given to cases where the Department is able to demonstrate the individual’s
specialisation is relevant to teaching across all years, for example, special needs or literacy or language
specialisms.
D22/026664 Limited Registration – DoE – Final year pre-service teacher for casual staff seeker pool
Issued 01/03/2022 Uncontrolled when printed Page 10 of 13
Details of teaching position and the pre-service teacher’s qualifications,
expertise and/or skills in a subject(s) relevant to the duties of the teaching
position.
Record the details of the teaching position offered to the pre-service teacher, including the subjects and year groups/ages being
taught. If the pre-service teacher will be teaching a range of year groups/ages in a subject, you can simply record a range (e.g.
years 1-6).
Note: terms such as relief, casual or duties other than teaching should not be used.
Ref
Learning area/subject(s)
Identify whether:
Early childhood, Primary,
Secondary or any
combination.
Include year group/ages as
relevant
The pre-service teacher’s expertise and skills relevant
to the subject/learning area and year group/age (link
qualifications if relevant).
For Secondary teaching qualifications, please indicate
the pre-service teacher’s major and minor study.
1.
2.
3.
4.
5.
D22/026664 Limited Registration – DoE – Final year pre-service teacher for casual staff seeker pool
Issued 01/03/2022 Uncontrolled when printed Page 11 of 13
Department of Education’s delegate declaration
This declaration is to be completed by the Department of Education’s delegate.
I, _____________________________________________________________________________________________________
(full name)
of ____________________________________________________________________________________________________
(address)
sincerely declare that
1. I have reviewed the information and evidence provided by the pre-service teacher and found that it appears to be true and
correct.
2. The information I have provided in this application is complete, true and correct.
Delegate’s signature: __________________________________________ Date:_________________
It is an offence under the Act to provide a false or misleading statement.
Sign Here
D22/026664 Limited Registration – DoE – Final year pre-service teacher for casual staff seeker pool
Issued 01/03/2022 Uncontrolled when printed Page 12 of 13
Payment calculator
Calculation of fee payable
Fee
Fee due
Application Fee
$223.50 any other application, including where the
application involves the consideration for approval of
qualification(s) conferred by an Australian or New Zealand
institution.
$223.50
Fee Payable:
$223.50
Insert Department of Education cost centre number
Please note:
• Application fees are non-refundable.
• Applications will not be processed without full payment of the application fee.
• An annual fee for the current financial year is applicable if your application is successful. The TRBWA will send the
pre-service teacher an invoice for the annual fee.
• The first year’s annual fee depends on when registration is granted:
o If registration is granted between 1 April and 30 September inclusive, the first year’s annual fee will be $90.50.
o If registration is granted between 1 October and 31 March inclusive, the first year’s annual fee will be $45.00.
This means, for example, that if registration is granted on 2 March, an annual fee of $45.00 will apply to cover the
29 day period of registration from 2 March to 31 March of that year.
• The TRBWA financial year is from 1 April to 31 March of the following year. All registered teachers will receive an
annual fee invoice every February for the full annual fee payment due for the next year of registration.
• Registration will be cancelled if the annual fee is not paid. This fee is due and payable when registration is granted.
• Annual fees can be paid up to and including the final year of the registration period.
D22/026664 Limited Registration – DoE – Final year pre-service teacher for casual staff seeker pool
Issued 01/03/2022 Uncontrolled when printed Page 13 of 13
To avoid unnecessary delays please check that the application is complete
using the following checklist:
The pre-service teacher has:
Completed the Nationally Coordinated Criminal History Check Application and Informed Consent Form.
Provided copies of sufficient identification documents required by the Nationally Coordinated Criminal History Check
Application and Informed Consent Form.
Completed the Verification of identity by an authorised third party form.
Provided evidence supporting any change of names reflected in the application (for example, a change of name
certificate issued by the Australian Registry of Births, Deaths and Marriages or an Australian marriage certificate
issued by a state or territory).
Included with this application supporting evidence relating to the application to fit2work for a criminal history check
from a country outside Australia (where applicable).
Provided the required evidence in respect to the qualification requirement for teacher registration (where applicable).
Provided the required evidence to demonstrate that the English language proficiency requirement for teacher
registration has been met (where applicable).
Lodging this application for registration
By email
The delegate has the responsibility of ensuring that the application has been completed, signed and includes all information.
The application form and supporting evidence may be emailed to: info@trb.education.wa.edu.au.
In the email subject line please include the application category, the pre-service teacher’s full name and registration number
(if the pre-service teacher holds or has previously held registration).
In the main body of the email, please detail all attachments that have been included with the application.
1 Version 3.0
Australian Criminal Intelligence Commission
UNCLASSIFIED
NATIONALLY COORDINATED CRIMINAL HISTORY CHECK
2019 MODEL APPLICATION AND INFORMED CONSENT FORM
Information about this form
Terms used in this form
Nationally coordinated
criminal history check
Describes both: the checking process
undertaken by the ACIC and police, and the
result received by the accredited body.
Commonly known as a ‘police check’.
You/the applicant
Individual seeking a nationally
coordinated criminal history check.
Accredited body
Organisation accredited with the ACIC
and responsible for submitting your
nationally coordinated criminal history
check.
Australian Criminal
Intelligence Commission
(ACIC)
Australian Government agency responsible
for facilitating access to nationally
coordinated criminal history checks.
Legal entity customer
Organisation the accredited body may use
to collect your application, including your
informed consent. This may be your
employer, benefits provider or issuing body.
Third party
Organisation the accredited body is
required by law to disclose your
personal information and police
information to.
Personal information
Information about you, including any
information contained in your identity
documents.
Police information
Information released as part of a nationally
coordinated criminal history check.
Who completes this form?
Accredited body
The accredited body or its legal entity customer pre-populates this
form with information in these sections: How to submit this form,
Contact details and question D1.
Applicant
You are required to provide your personal details and informed
consent to complete this form. You must also provide your identity
documents, as detailed in Documents required. If you are less than
18 years of age, this form must be completed by your parent or
legal guardian. You are completing this form to obtain a nationally
coordinated criminal history check.
What is a nationally coordinated criminal history
check?
A nationally coordinated criminal history check is conducted with
your informed consent to determine your suitability for
employment, a position of trust or as required by legislation. A
nationally coordinated criminal history check contains your personal
information, and any relevant police information about you,
according to the purpose of your nationally coordinated criminal
history check.
Privacy notice
How will my information be used?
The ACIC and Australian police agencies
The ACIC and Australian police agencies use the information on
this form and the applicant’s identity documentation:
to disclose police information relating to you, to the
accredited body named in question D1.
to update records held about you
for law enforcement, including purposes set out in the
Australian Crime Commission Act 2002 (Cth)
Accredited body
The accredited body or its legal entity customer uses the personal
information collected in this application to request a nationally
coordinated criminal history check and to assure itself of your
identity.
The accredited body may have a legislative basis for the
collection, use and disclosure of your personal information and
police information to a third party. If applicable, third parties are
listed in question D1. The ACIC recommends you seek more
information about relevant legislation from the accredited body.
The accredited body or its legal entity customer must advise you if
your personal information or police information will be
transferred or supplied to a location outside Australia, known as
the permitted offshore transfer arrangement. If this applies, the
legal name and location of the overseas entity are listed in
question D1. The ACIC recommends you seek more information
from the accredited body listed in D1.
You can contact the accredited body for more information on how
they handle your personal information using the contact details at
the end of this section.
How is my national coordinated criminal history
check result determined?
Police information is disclosed in accordance with applicable
spent conviction legislation and information release policies of the
Australian Government and state and territory governments.
These links may help you source information on spent convictions:
Australian Government www.legislation.gov.au
Australian Capital Territory www.legislation.act.gov.au
New South Wales www.legislation.nsw.gov.au
Northern Territory www.legislation.nt.gov.au
Queensland www.legislation.qld.gov.au
South Australia www.legislation.sa.gov.au
Tasmania www.thelaw.tas.gov.au
Victoria www.police.vic.gov.au
Western Australia www.legislation.wa.gov.au
How do I dispute my result?
If you do not agree with the results of your nationally
coordinated criminal history check, contact the accredited body
or, if applicable, its legal entity customer, using the contact
details on page 3 and tell them you want to dispute the result.
The accredited body or its legal entity customer accepts and
escalates all disputes.
NATIONALLY COORDINATED CRIMINAL HISTORY CHECK | 2019 MODEL APPLICATION AND INFORMED CONSENT FORM
2 Version 3.0
Australian Criminal Intelligence Commission
UNCLASSIFIED
Providing incomplete, false or misleading
information
You must take reasonable steps to ensure you provide accurate,
complete and up-to-date personal information. Withholding
and/or providing misleading, or false information on this form is a
Commonwealth offence and you may be prosecuted under the
Criminal Code Act 1995 (Cth).OW TO
If you become aware you have provided incorrect information you
must contact the accredited body as soon as possible.
Documents required
Minimum identity requirements
You must provide four documents with your completed form to
confirm your identity:
• one commencement of identity document to confirm your
birth in Australia or arrival in Australia
• one primary use in the community document to show the
use of your identity in the community; and
• two secondary use in the community documents
The accredited body or its legal entity customer will use these
documents to verify your identity with the personal information you
have provided on this form. The personal information contained in
your identity documents will be used to conduct a nationally
coordinated criminal history check, as you consent to in Section D.
The documentation you provide must include evidence of your full
name, date of birth and a photograph of you. If a photograph is not
provided on the identity documents presented, a passport-style
photograph certified by a person listed in Schedule 2 of the
Statutory Declarations Regulations 1993 (Cth) can be accepted in
addition to the four required documents.
Commencement documents
(a) full Australian birth certificate (not an extract or birth
card)
(b) current Australian passport (not expired)
(c) Australian visa current at time of entry to Australia as a
resident or tourist *
(d) ImmiCard issued by Department of Home Affairs
(previously the Department of Immigration and Border
Protection) that enables the cardholder to prove their visa
and/or migration status and enroll in services
(e) certificate of identity issued by Department of Foreign
Affairs and Trade (DFAT) to refugees and non-Australian
citizens for entry to Australia
(f) document of identity issued by DFAT to Australian
citizens or persons who have the nationality of a
Commonwealth country for travel purposes
(g) certificate of evidence of resident status.
* A Visa Entitlement Verification Online (VEVO) record may be
provided. If you are a New Zealand citizen on a Special Category Visa,
you can request your VEVO details from the Department of Home
Affairs via their website.
Primary documents
a) current Australian drivers licence, learner permit or
provisional licence issued by a state or territory, showing a
signature and/or photo and the same name as claimed
b) Australian marriage certificate issued by a state or
territory (church or celebrant-issued certificates are not
accepted)
c) current passport issued by a country other than Australia
with a valid entry stamp or visa
d) current proof of age or photo identity card issued by an
Australian Government agency in the name of the
applicant, with a signature and photo
e) current shooters or firearms licence showing a signature
and photo (not minor or junior permit or licence)
f) for persons under 18 years of age with no other Primary
Use in Community Documents, a current student
identification card with a signature or photo.
Secondary documents
a) certificate of identity issued by DFAT
b) document of identity issued by DFAT
c) convention travel document secondary (United
Nations) issued by DFAT
d) foreign government issued documents (for example,
drivers licence)
e) Medicare card
f) enrolment with the Australian Electoral
Commission
g) security guard or crowd control photo licence
h) evidence of right to an Australian government
benefit (Centrelink or Veterans’ Affairs)
i) consular photo identity card issued by DFAT
j) photo identity card issued to an officer by a police
force
k) photo identity card issued by the Australian Defence
Force
l) photo identity card issued by the Australian
Government or a state or territory government
m) Aviation Security Identification Card
n) Maritime Security Identification card
o) credit reference check
p) Australian tertiary student photo identity document
q) Australian secondary student photo identity
document
r) certified academic transcript from an Australian
university
s) trusted referees report
t) bank card
u) credit card.
Names
All names under which you have been or are currently known will
be included on the nationally coordinated criminal history check.
If you are concerned about the disclosure of details relating to your
previous known names, please contact the accredited body through
which you are submitting your check for a nationally coordinated
criminal history check for assistance.
Change of name
If you provide identity documents using a former name, you must
provide evidence of your name change. This means providing a
change of name certificate issued by the Australian Registry of
Births, Deaths and Marriages or an Australian marriage certificate
issued by a state or territory, in addition to your four identity
documents. Church or celebrant-issued certificates are not
accepted.
Special provisions for proof of identity
The ACIC recognises that in exceptional circumstances you may not
be able to meet the minimum proof of identity requirements.
Please contact the accredited body who will assess your ability to
meet the requirements and determine the most suitable method
to confirm your identity.
NATIONALLY COORDINATED CRIMINAL HISTORY CHECK | 2019 MODEL APPLICATION AND INFORMED CONSENT FORM
3 Version 3.0
Australian Criminal Intelligence Commission
UNCLASSIFIED
How to submit this form
Before submitting this form, ensure all sections are complete and
that you have signed and dated the form.
Submit your completed form and identity documents using these
instructions:
Contact details
You can contact the accredited body or its legal entity customer for
more information on the nationally coordinated criminal history
check process, how your personal information is handled and how
you can dispute your result.
Accredited body
Contact details
Legal entity customer (if applicable)
Contact details
Section A – Personal information
A1. Please read this before answering the following questions.
You must disclose all names you have been known by throughout
your life, including your primary name, name before marriage
(maiden name), and other previous names and/or alias names.
All names that you submit as part of your nationally coordinated
criminal history check, will appear on the check result. If you are
concerned about the disclosure of previous name, please contact
the accredited body.
With each additional name you provide, you must include your
family name, first given names and other given names (if
applicable).
Example:
When Lucianne was born, she was given the first name Lucianne,
second given name Jane and surname of Jones. When she was
married, she changed her surname to Smith. Lucianne commonly
uses the name Lucy when introducing herself in the community.
As such, Lucianne has four known names—her current name,
maiden name, the alias name she used before she got married and
the alias name she uses now. Lucianne needs to provide all four
names when completing this form, as follows:
Current name: Smith, Lucianne Jane
Maiden name: Jones, Lucianne Jane
Alias name: Smith, Lucy Jane
Previous name: Jones, Lucy Jane
Primary name
Family name
First given name(s)
Other given name(s)
Previous known name (if applicable)
Family name
First given name(s)
Other given name(s)
Name Type Maiden
Alias
Previous
Previous known name (if applicable)
Family name
First given name(s)
Other given name(s)
Name Type Maiden
Alias
Previous
📎
If more room is required, please list on a separate
sheet, sign and attach to this form.
Additional sheet attached? Yes
No
A2. Please read this before answering the following question.
You must select the gender that best describes how you
identify yourself within the community.
The gender details that you submit as part of your nationally
coordinated criminal history check, will be the gender that
appears on the check result.
The ACIC’s processes are aligned with the Australian
Government Guidelines on the Recognition of Sex and
Gender. If these Guidelines affect you and you would like
additional information specifically regarding this, please
contact the ACIC directly at npcs@acic.gov.au
Your gender
M
(Male)
F
(Female)
X
(Indeterminate/intersex/unspecified)
A3. Please read this before answering the following questions.
If you cannot provide all these details, contact the
accredited body or its legal entity customer.
When you are satisfied that this application and informed
consent form is complete and that you have all the required
identity documentation, please scan together with the
completed application form for teacher registration and email
to: info@trb.wa.gov.au.
Teacher Registration Board of Western Australia
Telephone: 08 9223 9100
Country callers: 1300 652 911
Email: info@trb.wa.gov.au
NATIONALLY COORDINATED CRIMINAL HISTORY CHECK | 2019 MODEL APPLICATION AND INFORMED CONSENT FORM
4 Version 3.0
Australian Criminal Intelligence Commission
UNCLASSIFIED
Your date of birth
Your place of birth
Suburb/town
State/territory
Country
A4. Please read this before answering the following questions.
Provide your current and previous residential addresses for
the past five years.
If you cannot provide full details, provide as much information
as possible. If you are unsure how to complete this section
contact the organisation that gave you this form.
Current residential address
Street address
Suburb/town
State/territory
Postcode
Country
Dates residing at address:
From
/ /
Previous residential address 1
Street address
Suburb/town
State/territory
Postcode
Country
Dates residing at address:
From
/ /
To
/ /
Previous residential address 2
Dates residing at address:
Previous residential address 3
Street address
Suburb/town
State/territory
Postcode
Country
Dates residing at address:
From
/ /
To
/ /
📎
If more room is required, please list on a separate
sheet, sign and attach to this form.
Additional sheet attached? Yes
No
A5. Please read this before answering the following questions.
If you have an Australian drivers licence and/or an
Australian firearms licence, you must provide the licence
number and the state or territory that issued your licence.
If you have a foreign drivers licence and/or a firearm licence
you must provide the licence number and the country that
issued your licence.
If you have a passport, you must provide the passport
number and the country that issued your passport.
Drivers licence number (if available)
Issued by (state/territory)
Firearm licence number (if available)
Issued by (state/territory)
Passport number (if available)
Issued by (country)
Section B - Purpose of the nationally
coordinated criminal history check
The purpose for your nationally coordinated criminal history check
helps determine what police information is disclosed on your result.
B1. Please read this before answering the following question.
For question B1, provide the following information:
1. position title, occupation, volunteer role or entitlement
being sought
2. proposed place of work (name of organisation or type of
workplace or industry)
3. location of the role (town and state/territory)
Street address
Suburb/town
State/territory
Postcode
Country
From
/ /
To
/ /
/ /
click to sign
signature
click to edit
NATIONALLY COORDINATED CRIMINAL HISTORY CHECK | 2019 MODEL APPLICATION AND INFORMED CONSENT FORM
5 Version 3.0
Australian Criminal Intelligence Commission
UNCLASSIFIED
Acronyms must not be used – except for the state/territory.
Example: Case worker, Youth Housing Facilities, Canberra,
ACT.
Example: volunteer in canteen, St Bebes, Canberra, ACT
Your position title, occupation, volunteer role or entitlement
Your proposed place of work (name of organisation or type of
workplace or industry)
The location of your work (town and state/territory)
B2. Please read this before answering the following question.
For question B2, indicate whether you will have
supervised/unsupervised contact with vulnerable groups as
part of the role you are applying for.
Vulnerable groups means:
- a child,
- an adult who is disadvantaged or in need of special
care, support or protection because of age, disability or
risk of abuse or neglect.
Contact means direct or indirect face-to-face contact,
phone contact or any type of communication over the
internet.
Supervision means in the presence of an adult who is
responsible for the safety or care of the vulnerable person.
Unsupervised means you will not be in the presence of an
adult who is responsible for the safety or care of the
vulnerable person.
Select the statement that best describes the role you are
applying for:
Supervised contact with vulnerable people
Unsupervised contact with vulnerable people
No contact with vulnerable people
Section C – Type of nationally coordinated
criminal history check
C1. Please read this before answering the following question.
You may request a volunteer check if you will hold a position
or perform a role where you will not receive any salary,
benefits or financial gain. This includes students undertaking
compulsory vocational placements.
Volunteer check type must not be selected for the
Australian Government’s Work for the Dole Scheme.
You must be able to validate the charity organisation or
volunteer position to support your selection of the
volunteer type.
What is the check type?
Standard
Volunteer
Section D – Informed consent
What is informed consent?
Your informed consent is needed before an accredited body can
request a nationally coordinated criminal history check for you.
Your informed consent means you:
have read and understood the information provided in this
form about how your personal information and any police
information relevant to you will be handled and disclosed
provide your permission for the accredited body to request a
nationally coordinated criminal history check on your behalf
provide your permission for the accredited body to disclose
your information to any organisation listed in D1 of this form.
How do I provide my informed consent?
An important aspect of providing informed consent is that you
understand what you are consenting to. It is important that you
read the consent statements in question D2 and, where required,
get clarification from the accredited body or its legal entity
customer, to ensure complete understanding. You must then sign
and date this form at D2, to give your informed consent.
Important: Please read this information about question D1.
The accredited body is required to complete the details at D1
before providing the form to you.
D1 provides the details of the organisations to whom your
personal and police information will be disclosed to.
In question D2, you will provide your informed consent for your
personal and police information to be disclosed to the ACIC,
Australian police agencies, law enforcement agencies, and any
organisations detailed in question D1.
D1. Organisations to whom the applicant’s personal and police
information will be disclosed
Accredited Body
Accredited body (legal name)
Address
Preferred contact details
ABN
Legal entity customer or related government entity
Legal entity customer or related government entity (legal
name)
X
X
Teacher Registration Board of Western Australia
151 Royal Street, EAST PERTH, WA 6004
08 9223 9100
69769481770
NATIONALLY COORDINATED CRIMINAL HISTORY CHECK | 2019 MODEL APPLICATION AND INFORMED CONSENT FORM
6 Version 3.0
Australian Criminal Intelligence Commission
UNCLASSIFIED
Address
Preferred contact details
ABN
Third parties (as required by law)
Third party 1 (legal name)
ABN
Third party 2 (legal name)
ABN
Permitted offshore transfer arrangements
Overseas entity (legal name)
Location (Country)
📎
If more room is required, please list on a separate
sheet, sign and attach to this form.
Additional sheet attached? Yes
No
D2. Please read this before answering the following question.
You must provide your name, read each statement carefully
and then print your name, sign and date to provide your
informed consent.
Applicant’s consent to submit a nationally coordinated
criminal history check
I,
Family name
First given name(s)
Other given name(s)
1. acknowledge that I/the applicant understand the
information on this form.
2. acknowledge that the accredited body named in D1 is
collecting information in this form to provide to the
Australian Criminal Intelligence Commission (ACIC) and
police agencies, for a nationally coordinated criminal
history check to be conducted for the purpose outlined in
Section B of this form.
3. have fully and accurately completed this form, and the
personal information I/the applicant, have provided
relates to me/the applicant, and contains the full name
and all names previously used by me/the applicant.
4. acknowledge that withholding and/or providing
misleading or false information on this form and in any
supplied identity documents is a Commonwealth offence
and may lead to prosecution under the Criminal Code Act
1995 (Cth).
5. acknowledge that personal information that I/the
applicant provided on this form and on the supplied
identity documents may be disclosed to the accredited
body named in Section D of this form (including
contractors, legal entity customers, related bodies or third
parties named in D1 of this form in Australia or overseas,
if applicable).
6. acknowledge that any information sent by mail or
electronically, in relation to this form, including identity
documents, is sent at my/the applicant’s risk and I/the
applicant, am aware of the consequences of sending
information in these ways.
7. acknowledge that I/the applicant am aware that I/the
applicant am providing consent for a nationally
coordinated criminal history check to be conducted using
all personal information provided in this form and
provided in suppled identity documents.
8. understand and consent to police information relating to
me/the applicant, being disclosed in accordance with the
purpose identified in Section B of this form, and applicable
legislation and information release policies (including
spent convictions legislation described in Australian
Government and state or territory legislation).
9. give consent to:
a. the ACIC and police agencies using and disclosing
my/the applicant’s personal information that I/
the applicant, have provided in this form and
personal information contained in my supplied
identity documents to conduct a nationally
coordinated criminal history check.
b. the ACIC disclosing the police information sourced
from the police agencies to other approved bodies
and the accredited body named in D1 of this form.
c. the accredited body named in D1 of this form
disclosing to the legal entity customer, third
parties and any permitted offshore transfer
arrangements also detailed in D1, my/the
applicant’s personal information and police
information to assess my/the applicant’s suitability
for the purpose identified in Section B of this form.
10. acknowledge that it is usual practice for my/the
applicant’s personal information and police information
to be used by police agencies and the ACIC for law
enforcement, including purposes set out in the Australian
Crime Commission Act 2002 (Cth).
NATIONALLY COORDINATED CRIMINAL HISTORY CHECK | 2019 MODEL APPLICATION AND INFORMED CONSENT FORM
7 Version 3.0
Australian Criminal Intelligence Commission
UNCLASSIFIED
Applicant
Print name
Signature
Date
/ /
Parent or legal guardian
(where the applicant is under the age of 18)
Print name
Signature
Date
/ /
Authorised agent
(person responsible for the applicant, such as a legal
representative)
Print name
Signature
Date
/ /
Section E - Office use only
Accredited body or its legal entity customer declaration.
E1. What is the nationally coordinated criminal history check
category for this check?
For example: Employ/probity/licence.
E2. Collected Identity Documentation
1) Commencement of identity document:
Type of document collected:
Name as it appears on the identity document:
Document identifier number:
2) Primary use in the community document:
Type of document collected:
Name as it appears on the identity document:
Document identifier number:
3) Secondary use in the community document:
Type of document collected:
Name as it appears on the identity document:
4) Secondary use in the community document:
Type of document collected:
Name as it appears on the identity document:
5) Change of name document (if applicable):
Type of document collected:
Previous name as it appears on the document:
Current name as it appears on the document:
E3. The accredited body or its legal entity customer declares that:
The correct check type has been selected for this check
and they have verified the legitimacy of this claim.
They are satisfied as to the applicants’ identity and have
verified the linkage between the Applicant and the
claimed identity.
Staff member
Print name
Signature
Date
/ /
Verification of identity by an authorised third party
This form is for applicants for teacher registration to have an authorised third party verify their identity on behalf
of the TRBWA.
All applicants for teacher registration in Western Australia are required to provide consent for a national
criminal record check. In order to meet the requirements for a national criminal record check, an applicant for
teacher registration in Western Australia must have their identity verified by an authorised third party.
Who is an authorised third party?
For the purposes of teacher registration, an authorised third party is able to verify the identity of an applicant
for teacher registration on behalf of the TRBWA.
An authorised third party is an occupation or person as listed in the Statutory Declaration Regulations 2018.
List of ‘Authorised Witnesses’ for TRBWA registration processes
How to complete this form
1. Print this form.
2. Present all the original identity documents, (including the photo identity document) as listed in Section
2 below, to an authorised third party to undertake an identity verification.
3. The authorised third party must:
a. sight all identity documents;
b. make a face-to-face visual comparison between the applicant and the photo
identification document, and
c. complete sections 3 and 4.
4. Ensure all sections of this form are complete.
5. Upload a copy of this form to your application for registration within the ‘Verification of Identity’ section.
Section 1 - Applicant's personal details
First Name
Middle Name (if any)
Family Name
Date of Birth
Address
Section 2 - Identity documents used to apply for teacher registration
Identity Document
Document Type
Expiry Date
Commencement document
Primary document
Secondary document
Secondary document
Section 3 - Authorised third party details
Full Name
Profession/occupation
Telephone number
Email address
Section 4 - Authorised third party verification
I declare that I have sighted the Applicant’s identity documents as listed above and the Applicant’s identity has
been confirmed via a face-to-face comparison with the photographic identification document. I am satisfied as
to the correctness of the Applicant’s identity.
Signature:
Date:
Identification photo
If your identity documents do not include a photograph you must submit a passport-style photograph certified by a
person listed on the [‘Authorised Third Parties for the Verification of Identity’ information sheet.]
The authorised third party must sight a recent passport-style photograph of yourself and clearly print the
following information on the back of that photograph:
1. “This is a true image of (full name of the applicant)”;
2. their name and position or role e.g. Justice of Peace;
3. signature; and
4. date of signature.
Upload a copy of both sides of the certified photograph to your application for registration within the Identification
photo section.
1
2018/23382
Issued 30/04/2020 Uncontrolled when printed Page 1 of 2
List of ‘Authorised Witnesses’ for TRBWA registration processes
Please find below a list of occupations and persons authorised to:
1. witness the statutory declaration as part of the Mutual Recognition Notice, or other TRBWA
purposes; or
2. verify the identity of an applicant for teacher registration with the TRBWA.
Please note, for the purposes of the Mutual Recognition Notice, the witnessing of the Statutory
Declaration must be done in person and not remotely.
Verification of identity may be undertaken outside Australia, if it is undertaken by a person on the
following list who holds an official, administrative connection to Australia, except for a notary public
(however described). For example, a doctor who is registered to practise medicine in Australia may
verify the identity of an applicant for the purposes of teacher registration when they are overseas. A
doctor who is registered to practise medicine in a country other than Australia, however, may not.
List of occupations and persons
A. A person who is currently licensed or
registered to practise in Australia under a
law of the Commonwealth, a State or
Territory in one of the following
occupations:
1. Architect
2. Chiropractor
3. Dentist
4. Financial adviser or financial planner
5. Legal practitioner
6. Medical practitioner
7. Midwife
8. Migration agent registered under
division 3 of part 3 of the migration act
1958
9. Nurse
10. Occupational therapist
11. Optometrist
12. Patent attorney
13. Pharmacist
14. Physiotherapist
15. Psychologist
16. Trade marks attorney
17. Veterinary surgeon
B. A person who is enrolled on the roll of the
Supreme Court of a State or Territory, or
the High Court of Australia, as a legal
practitioner (however described); or
C. A person who is listed below:
1. Accountant who is:
(a) a fellow of the National Tax
Accountants' Association, or
(b) a member of any of the following:
i. Chartered Accountants
Australia and New Zealand
ii. the Association of Taxation
and Management
Accountants
iii. CPA Australia
iv. the Institute of Public
Accountants
2. Agent of the Australian Postal
Corporation who is in charge of an office
supplying postal services to the public
3. APS employee engaged on an ongoing
basis with 5 or more years of continuous
service who is not specified in another
item of this Part
4. Australian Consular Officer or Australian
Diplomatic Officer (within the meaning of
the Consular Fees Act 1955)
5. Bailiff
6. Bank officer with 5 or more continuous
years of service
7. Building society officer with 5 or more
years of continuous service
8. Chief executive officer of a
Commonwealth court
9. Clerk of a court
10. Commissioner for Affidavits
11. Commissioner for Declarations
12. Credit union officer with 5 or more years
of continuous service
13. Employee of a Commonwealth authority
engaged on a permanent basis with 5 or
more years of continuous service who is
not specified in another item in this Part
14. Employee of the Australian trade and
investment Commission who is:
(a) in a country or place outside
Australia; and
(b) authorised under paragraph 3(d) of
the Consular Fees Act 1955; and
(c) exercising his or her function in that
place
15. Employee of the Commonwealth who is:
(a) in a country or place outside
Australia; and
2
2018/23382
Issued 30/04/2020 Uncontrolled when printed Page 2 of 2
(b) authorised under paragraph 3(c) of
the Consular Fees Act 1955; and
(c) exercising his or her function in that
place
16. Engineer who is:
(a) a member of Engineers Australia,
other than at the grade of student; or
(b) a Registered Professional Engineer
of Professionals Australia; or
(c) registered as an engineer under a
law of the Commonwealth, a State or
Territory; or
(d) registered on the National
Engineering Register by Engineers
Australia
17. Finance company officer with 5 or more
years of continuous service
18. Holder of a statutory office not specified in
another item in this list
19. Judge
20. Justice of the peace
21. Magistrate
22. Marriage celebrant registered under
subdivision c of division 1 of part iv of
the marriage act 1961
23. Master of a court
24. Member of the Australian defence force
who is:
(a) an officer; or
(b) a non-commissioned officer within
the meaning of the Defence Force
Discipline Act 1982 with 5 or more
years of continuous service; or
(c) a warrant officer within the meaning
of that Act
25. Member of the Australasian Institute of
Mining and Metallurgy
26. Member of the Governance Institute of
Australia Ltd
27. Member of:
(a) the parliament of the
Commonwealth; or
(b) the parliament of a State; or
(c) a Territory legislature; or
(d) a local government authority
28. Minister of religion registered under
Subdivision A of Division 1 of Part IV of
the Marriage Act 1961
29. Notary public, including a notary public
(however described) exercising functions
at a place outside:
(a) the Commonwealth; and
(b) the external territories of the
Commonwealth
30. Permanent employee of the Australian
Postal Corporation with 5 or more years
of continuous service who is employed in
an office supplying postal services to the
public
31. Permanent employee of:
(a) a State or Territory, or a State or
Territory authority; or
(b) a local government authority;
with 5 or more years of continuous
service, other than such an employee
who is specified in another item of this
Part
32. Person before whom a statutory
declaration may be made under the law of
the State or Territory in which the
declaration is made
33. Police officer
34. Registrar, or deputy registrar, of a court
35. Senior executive employee of a
Commonwealth authority
36. Senior executive employee of a State or
Territory
37. SES employee of the Commonwealth
38. Sheriff
39. Sheriff's officer
40. Teacher employed on a permanent full-
time or part-time basis at a school or
tertiary education institution.
Important information about privacy
Your personal information is protected by law. Please refer to the TRBWA Privacy Policy for further
information.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

23059649 (Services Australia)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 13 March 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document