Fillable APPLICATION FORM NATIONAL POLICE CHECK (NPC) (Australian National University)

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APPLICATION FORM NATIONAL POLICE CHECK (NPC) (Australian National University)

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The APPLICATION FORM NATIONAL POLICE CHECK (NPC) (Australian National University) form is 6 pages long and contains:

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  • 63 check-boxes
  • 133 other fields

Country of origin: AUSTRALIA
File type: PDF

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Payment
Mandatory Details
Fingerprints (attached)
Consent
Proof of IDs
Fingerprints (paid)
Notes:
Ref No:
Note: If you need to record additional names please use Attachment B. Page 1 of 5
NATIONAL POLICE CHECK (NPC)
APPLICATION FORM
Website: www.afp.gov.au
Enquiries: AFP-NationalPoliceChecks@converga.com.au
ABN: 17 864 931 143
Office Hours: 8am to 5pm, Monday to Friday (except ACT Public Holidays)
Please complete this form by referring to the Application Completion Guide. If completing manually, use BLOCK LETTERS and black ink. Mark check boxes with a cross (X).
This application form is NOT to be scanned and loaded during the online application process.
SECTION 1: Type of check required
(this section must be completed - select only one)
Name Check Only (Fee: $42) Name and Fingerprint Check (Fee: $99 if fingerprints are taken and paid, $139 if not paid)
SECTION 2: Fingerprints (Optional) (complete only where fingerprints are required and/or authorised by law)
Police Station: Officer’s Name & No:
Date Taken:
(DD MM YYYY)
AFP NPC FORM-5021
Please note that a fingerprint check is only required under very limited circumstances. Please ensure that you are actually required to have a fingerprint check conducted
before going to the expense of this level of check by checking with the organisation/department requesting the check.
Note: Fingerprints can be taken by your local police jurisdiction or the AFP. Where fingerprints are taken by the AFP and the AFP charges for this service a receipt must be
obtained and supplied to Criminal Records with this application.
SECTION 4: Other names you have used (including former, maiden name/s etc)
Family Name / Surname :
First Name / Given Name:
Other Given Names:
Former Name Also known as
Family Name / Surname :
First Name / Given Name:
Other Given Names:
Former Name Also known as
SECTION 3: Details of Applicant
(this section must be completed)
Family Name / Surname :
First Name / Given Name:
Other Given Names:
Were you born in Australia?
Yes
No
Suburb / Town of Birth:
Country of Birth:
State:
Daytime Contact Number:
Email Address
(optional):
Australian Driver’s Licence No:
Issuing State:
Date of Birth:
(DD MM YYYY)
Date of Birth:
(DD MM YYYY)
Date of Birth:
(DD MM YYYY)
Telephone: 02 6140 6502 Fax: 1300 549 456
Page 2 of 5
SECTION 5: Current & Previous Residential Addresses
(this section must be completed)
Previous Residential Address (must not be a PO Box or Business Address) - Note: To record additional addresses please use Attachment C.
Unit No / Street No /
Street Name:
Suburb / Town / Locality:
Country:
Postcode: State:
Current Residential Address (must not be a PO Box or Business Address)
Unit No / Street No /
Street Name:
Suburb / Town / Locality:
Country:
Postcode: State:
Date you started living at this address: (DD MM YYYY)
(DD MM YYYY)
Date you started living at this address:
AFP NPC FORM-5022
This can be a PO Box or Business Address. Note: If not completed, the certificate will be sent to the applicant at the Current Residential Address specified
in Section 5.
(optional) I authorise the Police Certificate to be forwarded to the following person/organisation
SECTION 6: Mailing Address for Police Certificate
Unit No / Street No /
Street Name:
Suburb / Town / Locality:
Country:
State:Postcode:
(this section must be completed)
Cardholder’s Name:
Credit Card Number:
Bank Cheque
Money Order
I authorise the AFP or their agent to process the relevant
application amount from the above credit card account.
NB: The amount to be deducted is as per the selected
fee specified on Page 1 (Section 1) of this form,
plus a surcharge where payment is by Credit Card.
FOR OFFICE USE ONLY
Payment Confirmation No:
Processed Amount: (AUD)
SECTION 7: Payment Details
Attn. To / Organisation:
Expiry Date: (MM YY) CVC Number:
Card Declined
Credit Card/Debit Card (please complete card details below)
Previous Residential Address (must not be a PO Box or Business Address) - Note: To record additional addresses please use Attachment C.
In the event you have not resided in your current location for 10 years or greater, please provide details of your previous residential addresses.
The CVC Number is a 3 digit number on the back of your VISA
®
and MasterCard
®
,
or a 4 digit number on the front of your American Express
®
credit card
MasterCard Debit Card
Visa Debit Card Visa Credit Card
(Surcharge: 0.242% 0.539% 0.506% 1.023% 1.595%)
Amex
MasterCard Credit Card
Page 3 of 5
SECTION 8: Purpose of Check
(Choose one purpose only from the following list)
If the purpose for your NPC is not listed or you are unsure please call the National Police Check Help Desk on 02 6140 6502 between 8am and 5pm (Australian EST).
AFP NPC FORM-5023
Offences recorded in the ACT that will be released
(Spent Convictions Act 2000)
ACT Purpose / Employment
Code Number
Please note that the NPC purposes in this section are ONLY for applicants living or working in the Australian Capital
Territory (ACT). If you live outside the ACT and you require a pre-employment/standard disclosure National Police
Check, you should contact your local Police service.
Offences recorded in the Commonwealth that will be released
(Part VIIC Crimes Act 1914)
Commonwealth Employment / PurposeCode Number
Disabled Care Provider/Worker - in the ACT
Child Care Provider/Worker - in the ACT
Brothel or Escort Agency Owner/Operator/Interested Party - in the ACT
Aged Care Provider/Worker - in the ACT
Pre-Employment/Standard Disclosure - in the ACT
Teacher/Teacher’s Aide - in the ACT
Working in a School - in the ACT
Child/Aged/Disabled Care Provider/Worker - in the ACT
Prison Officer - in the ACT
Interactive Gambling Licence/Casino Employee - in the ACT
Firearms Licence/Permit - in the ACT
Fire Fighting/Prevention - in the ACT
All ACT offences. Other State/Territory offences as legislation permits
All ACT offences. Other State/Territory offences as legislation permits
All ACT offences. Other State/Territory offences as legislation permits
All ACT offences. Other State/Territory offences as legislation permits
Unspent offences and offences of Arson or Attempted Arson
Unspent offences
All ACT offences. Other State/Territory offences as legislation permits
All ACT offences. Other State/Territory offences as legislation permits
All ACT offences. Other State/Territory offences as legislation permits
All ACT offences. Other State/Territory offences as legislation permits
All ACT offences. Other State/Territory offences as legislation permits
All ACT offences. Other State/Territory offences as legislation permits
Security Licence (Security Guard) - in the ACT All ACT offences. Other State/Territory offences as legislation permits
Hospital Employment - in the ACT All ACT offences. Other State/Territory offences as legislation permits
Care of Intellectually Disabled Persons
Australian Securities and Investments Commission Consumer Credit/Financial
Services Licensing Requirements
Aged Care Key Personnel
Unspent offences
Unspent offences
Care, Instruction or Supervision of Children
Civil Aviation Safety Authority ASSC
Immigration Detention Centre Employment
Unspent offences
Care, Instruction or Supervision of Children/Care of Disabled Persons/
Aged Care Staff/Volunteers
Overseas Visa - Supply to a Country Other than Australia
Overseas Employment - Aged/Disabled Care
Overseas Employment - General Employment
Overseas Employment - Teaching
Overseas Employment - Working with Children
Overseas Employment - Nursing, Hospital Employment
Other Commonwealth Purpose ONLY
Unspent offences
** If you need a NPC for other than a Commonwealth related purpose, (eg working for a
Commonwealth Department or Agency) you must contact your local Police.
Aged Care Staff/Volunteers Unspent offences and offences against the person where State/
Territory legislation permits
Unspent offences and offences against the person where State/
Territory legislation permits
Unspent offences as well as any (i) sexual offence, (ii) other offence
against the person if the victim of the offence was under 18 at the time
the offence was committed where State/Territory legislation permits
Unspent offences as well as any (i) sexual offence, (ii) other offence
against the person if the victim of the offence was under 18 at the time
the offence was committed, (iii) offences against the person where
State/Territory legislation permits
Unspent offences and offences involving violence where State/
Territory legislation permits
Immigration/Citizenship – for Supply to the Department of Home Affairs All Commonwealth offences. Other State/Territory offences as
legislation permits
All Commonwealth offences. Other State/Territory offences as
legislation permits
All Commonwealth offences. Other State/Territory offences as
legislation permits
All Commonwealth offences. Other State/Territory offences as
legislation permits
All Commonwealth offences. Other State/Territory offences as
legislation permits
All Commonwealth offences. Other State/Territory offences as
legislation permits
All Commonwealth offences. Other State/Territory offences as
legislation permits
Superannuation Trustee/Custodian/Investment Manager or Responsible Officer of a
Body Corporate that is a Trustee, Investment Manager or Custodian of a
Superannuation Entity
Unspent offences and offences in respect of dishonest conduct where
State/Territory legislation permits
AFP NPC FORM-5024
Attachment A: Proof of Identity
(this section must be completed)
A minimum of 100 points of identification has to be provided with the application. Please ensure that only photocopies of the original documents are attached.
Required on document
N = Name, P = photo
A = Address, S = Signature
You must supply at least ONE Primary document
Foreign documents must be accompanied by an official translation
Points
Worth
Points gained
(applicant to fill)
Tick if
included
Certificate of Identity issued by the Australian Government to refugees and non Australian citizens for
entry to Australia
Photo identification card issued for Australian regulatory purposes (e.g. Aviation/Maritime Security
identification, security industry etc.)
Documents issued outside Australia (equivalent to Australian documents). Must have official
translation attached
Foreign Passport (current)
Australian Passport (current or expired last 2 years but not cancelled)
Australian Citizenship Certificate
Full Birth certificate (not extract)
Australian Driver License/Learner’s Permit
Current (Australian) Tertiary Student Identification Card
Government employee ID (Australian Federal/State/Territory)
Defense Force Identity Card (w/ photo or signature)
Department of Veterans Affairs (DVA) card
Centrelink card (with reference number)
Birth Certificate Extract
Birth card (NSW BDM only)
Medicare card
Credit card or account card
Australian Marriage certificate (Registry issue only)
Decree Nisi / Decree Absolute (Registry issue only)
Change of name certificate (Registry issue only)
Bank statement
Property lease agreement - current address
Taxation assessment notice
Australian Mortgage Documents
Rating Authority - eg Land Rates
Utility Bill - electricity, gas, telephone (less than 12 months old)
Reference from Indigenous Organisation
Note: Documents do not need to be certified unless a translation is being provided or you are supplying a power of attorney
SECTION 9: Applicant’s Consent
(this section must be completed)
i.
ii.
iii.
iv.
v.
vi.
vii.
I acknowledge I have read all the instructions while completing this application and I am aware exclusions from spent convictions legislation may apply to some categories of NPCs.
The personal information I have provided in this application (including fingerprints if supplied) and all the attachments (if any) relate to me and are correct.
I acknowledge the details contained in this application, including fingerprints where relevant, will be forwarded to the AFP, the Australian Criminal Intelligence Commission, and/or the Police Services of the States or
Territories of the Commonwealth of Australia.
I consent to the AFP and any other Australian police force extracting details of any convictions, findings of guilt or pending court proceedings relating to me, including in relation to any traffic offence, and providing
that information to me or to the Employer/Organisation named in Section 6.
I acknowledge the information provided in this application will not be used without my prior consent for any other purpose, unless otherwise authorised by law.
I acknowledge that any information provided in this application or disclosed by the police as a result of the records check may be taken into account by any organisation to whom I present the results of the records check in
assessing my suitability to receive the entitlement.
I acknowledge that only details contained in this application or on attachments signed by me will be checked and that should I subsequently require further names and/or details to be checked then I will be
required to submit a new application and payment.
Parent/Guardian’s Name:
Parent/Guardian’s
Signature:
Date:
Applicant’s Signature: Date:
If you are under 18 years of age (as at the date of the application), please provide consent below from a parent/guardian.
viii.
I understand that it is an offence to provide false or misleading information in this application, or omit to provide information that may result in this application being false or misleading.
Page 4 of 5
0
AFP NPC FORM-5025
Prior to submitting your application, please complete the checklist below to ensure your request can be processed in a timely manner. Failure to complete or supply any
part of the application may result in it being returned prior to processing.
All required details in Sections 1 to 9 are complete.
I can be reached during business hours on the phone number I have provided in section 3.
I have attached photocopies of my identification, for documents selected in attachment A above.
I have provided my credit card details for electronic payment or I will attach a cheque or money order payable to the AFP for the current fee.
(optional) If a fingerprint check is required, I have provided my fingerprints and if relevant, a copy of the receipt for payment.
Once all the above steps have been completed, attach your photocopied identification documents and payment to the application form and post to:
Australian Federal Police
Criminal Records
Locked Bag 8550
CANBERRA CITY ACT 2601
Submission Checklist
Page 5 of 5
Optional Attachment
AFP NPC FORM-5026
Attachment C: Previous Residential Address
Unit No / Street No /
Street Name:
Suburb / Town / Locality:
Country:
Postcode: State:
Unit No / Street No /
Street Name:
Suburb / Town / Locality:
Country:
Postcode: State:
Unit No / Street No /
Street Name:
Suburb / Town / Locality:
Country:
Postcode: State:
(use only if required - must not be a PO Box or Business Address)
Date you started living at this address: (DD MM YYYY)
Date you started living at this address: (DD MM YYYY)
Date you started living at this address: (DD MM YYYY)
Attachment B: Other names you have used
(use only if required)
Family Name / Surname :
First Name / Given Name:
Other Given Names:
Former Name Also known as
Family Name / Surname :
First Name / Given Name:
Other Given Names:
Former Name Also known as
Family Name / Surname :
First Name / Given Name:
Other Given Names:
Former Name
Also known as
Date of Birth:
(DD MM YYYY)
Date of Birth:
(DD MM YYYY)
Date of Birth:
(DD MM YYYY)
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APPLICATION FORM NATIONAL POLICE CHECK (NPC) (Australian National University)

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Completed 21 March 2022

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