University of Southern Queensland
It is an offence for a disqualified person to sign a blue card application form as stipulated
on both Blue Card Services and Professional Experience websites.
(Insert the full name of the applicant)
confirm that I have been appropriately warned by the BELA Professional Experience office
at the University of Southern Queensland and understood what is classified as a
disqualified person and the associated offences.
I declare that I am not a disqualified person.
(Signature of applicant)
DJAG 039.V1 OCT16
Confirmation of identity
Working with Children (Risk Management and Screening) Act 2000
This form is to be completed by a prescribed person where a blue/exemption card applicant cannot have their
identification sighted by their organisation because either: the applicants usual residence is more than 50km from
the business address of the organisation; or the applicant has a disability aecting their mobility.
Note: This form must accompany the blue/exemption card application form.
Department of Justice and Attorney-General
Blue Card Services
Part A – Applicant's details
Name of applicant
Part B – Proof of identity
A prescribed person is responsible for sighting the applicant’s identification documents. A prescribed person is a:
Justice of the Peace • Commissioner for Declarations • Lawyer • Police Ocer
The prescribed person must check two current, original identification documents from the applicant which collectively show the
applicant’s full name, date of birth and signature. The applicant’s details on their identification documents must match the details
provided on the application form.
One of the following combinations must be used: EITHER
List 1
List 1
(one must show a signature)
List 2
(one must show a signature)
List 1
If one of the valid combinations above cannot be provided, complete and attach a ‘Request to consider alternative identification’ form.
Please indicate which identification documents have been sighted by placing a in the box.
Driver licence/learner permit/proof of age card
Document No:
Issued in the state of:
Australian Passport (current or expired in the last 2 years)
Birth certificate (or extract)
Proof of Australian citizenship or permanent residency
Overseas Passport (current)
Country of issue:
Pension Concession card/Department of Veterans’
Aairs Entitlement card/Seniors Health card/Health care
card/any other current financial entitlement card issued
by Department of Human Services.
Credit card or bank card
(do not attach copy)
Positive Notice Blue or Exemption card
Student identification card issued by an education
institution (with photo and signature)
Queensland Gaming Machine Licence
Medicare card
Queensland crowd controller/private investigator/
security ocer licence
Passbook or account statement issued by a financial
institution dated in the last 6 months
Australian taxation assessment notice dated in the
last 6 months
Queensland Licence issued under the Weapons Act 1990
If possible, please attach a photocopy of the documents sighted for verification purposes (excluding credit or bank cards).
DJAG 039.V1 OCT16
I declare that:
• I have checked the name, date of birth and signature details provided in this form and confirm they match those on the
identification documents sighted; and
• I understand that it is an oence to provide a false or misleading statement or document.
I am a:
Justice of the Peace
Commissioner for Declarations
Police Ocer
Name of applicant
Signature of prescribed person
Name of prescribed person
Date of signature
Stamp and Registration
No. (if applicable)
Part C – Declaration by prescribed person
Privacy notice
The Working with Children (Risk Management and Screening) Act 2000 allows the collection of personal information to assess your
eligibility to be issued with a blue/exemption card. Information will be provided to Queensland Police, and may be provided to police,
courts, prosecuting authorities or other authorised agencies as part of the screening process. Information may also be given to:
certain disciplinary bodies to obtain relevant disciplinary information; and/or
your employer, any supervisory body, or other person you have authorised to discuss your application on your behalf.
Personal information will only be provided to other persons or agencies with your permission or where required by law.
For more information about the blue card system and your obligations go to
Blue Card Services, Department of Justice and Attorney-General
07 3211 6999 or 1800 113 611
PO Box 12671, Brisbane George Street QLD 4003
07 3035 5910
53 Albert Street, Brisbane QLD 4000