Fillable CLC Permit COVID-19 Declaration - CLC-declaration-form post June 5

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CLC Permit COVID-19 Declaration - CLC-declaration-form post June 5

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The CLC Permit COVID-19 Declaration - CLC-declaration-form post June 5 form is 2 pages long and contains:

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  • 11 check-boxes
  • 15 other fields

Country of origin: AUSTRALIA
File type: PDF

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This declaration must be attached to all online permit applications or forwarded to
permits@clc.org.au
28
th
May 2020 Page 1 of 2
COVID-19 Declaration for access to Aboriginal
Land/Communities
To minimise the transmission of pandemic disea
se during a public health threat all permit applicants must
declare all travel in the past 14 days as well as any current illness.
If any applicant has tested positive to Covid-19, are displaying symptoms or have travelled to a high-risk
region within the past 14 days they must cease travel to remote communities and any permit for travel is
invalidated.
Have you travelled outside of Australia (overseas) and or entered into the
Northern Territory (from overseas or interstate) in the last 14 days?
Yes ☐
No ☐
If you have ti
cked YES, provide details of travel below.
What towns or regions have you visited outside the Northern Territory
in the last 14 days?
Dates visited
(eg. 21/03/20 to
24/03/20)
This declaration must be attached to all online permit applications or forwarded to
permits@clc.org.au
28
th
May 2020 Page 2 of 2
Are you applying for an exemption from border quarantine in order to directly
enter Aboriginal land after crossing the NT border?
Yes ☐ No ☐
If yes, you must provide evidence of your exemption quarantine conditions. CLC will assess these before
issuing a permit.
Do you have any of the following COVID-19 symptoms?
Cough ☐
Fever ☐
Cough without fever ☐
Sore throat ☐
Body aches, muscle or joint pain ☐
Lethargy ☐
Other (please specify)
☐
Declaration
I, hereby declare that:
• I have accurately provided all trav
el and illness information required of me in regard to
the past 14 days
• I have not knowingly come into contact with positive cases of COVID-19
• If I travel outside the Northern Territory during the period of a valid permit, I must re-
submit an updated CLC COVID-19 Declaration to permits@clc.org.au
• If I have any of the symptoms listed above, my permit to Aboriginal land is invalidated.
• In the event of a positive test for COVID-19 my permit will be invalidated
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CLC Permit COVID-19 Declaration - CLC-declaration-form post June 5

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Completed 3 July 2020

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