Last updated November 2019 Please check the ACECQA website to ensure that you are using the current version
© 2019 Australian Children’s Education and Care Quality Authority
NQF Qualification Assessment
Authorised Representative Declaration and Consent Form
Declaration and Consent
Authorised representative declaration and consent (if applicable)
Please tick each clause below and sign the declaration in the presence of the witness. The witness must be one of the
persons authorised to certify documents outlined in the application form.
I, (the applicant’s authorised representative) declare
I have been authorised by the applicant to discuss, request and provide information about this
application on their behalf.
I understand that providing false or misleading information is an offence and all the information I have
provided is true and correct to the best of my knowledge and is as was conveyed to me by the
I understand that the applicant may withdraw this authority at any time.
Day Month Year
Signature of Date
Day Month Year
Signature of Date
Authorised witness name
Authorised witness occupation
or JP number
/ /
/ /