ArrowEnergy‐JamesCookUniversity
AboriginalorTorresStraitIslanderDescentForm
About this reference
This referee can only be filled out by an ‘authorised referee’.
Authorised referees include:
Chairperson, Secretary or CEO on an incorporated
Indigenous organisation (including lands councils,
community councils, housing organisations etc)
Sc
hool principa
l
Minister of religion
Treating health professional
Manager of Aboriginal medical servic
e
Centrelink staff, Centrelink agent or other Government
employee of 5 or more years.
1.
C
laimant Personal Detail
s
F
amily name
First name
Second name
Other names used or been known by (e.g. name at birth,
nickname, aboriginal or tribal name, alias).
Date of birth
Place of birth
Address
Applicants signature
Date
2. Statement by authorised re
feree
I confirm that:
The applicants has signed this in my presence, or
the applicant is currently km/hours away and
I have identified them as the person named at question 1
by my personal knowledge of their circumstances.
I am the authorised referee (as listed in column 1), and I
have known the applicant:
professionally
personally
for years
I can confirm the applicant information from
:
Pers
onal knowledge Church records
Organisation records Medical records
Council records School records
Other (give details
below)
I can confirm that the applicant is an identified member of
the <Insert traditional owner group>
3. Authorised referee’s detail
s
Full name
Title or official position
ABN (if applicable)
- - -
Phone number
Giving false or misleading information is an offence.
Referee’s signature
Seal or stamp
x
( )
x
click to sign
signature
click to edit
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click to sign
signature
click to edit
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