Fillable Confirmation Of Identity Valid Until 31 MARCH 2020 (James Cook University of North Queensland)

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Confirmation Of Identity Valid Until 31 MARCH 2020 (James Cook University of North Queensland)

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Australia forms for James Cook University of North Queensland

BROWSE JAMES COOK UNIVERSITY OF NORTH QUEENSLAND FORMS

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1
DJAG 039.V3 MAR19
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 applicant’s 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.
Part A – Applicant's details
Name of applicant
Date of birth
Signature
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)
OR
+
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.
LIST 1
SIGNATURE DOCUMENT
Driver licence/learner permit/proof of age/photo
identification card
Licence/reference No:
Issued in the state of:
Australian Passport (current or expired in the last 2 years)
NON-SIGNATURE DOCUMENT
Birth certificate (or extract)
Proof of Australian citizenship or permanent residency
Overseas Passport (current)
Country of issue:
LIST 2
SIGNATURE DOCUMENT
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
NON-SIGNATURE DOCUMENT
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).
D D M M Y Y Y Y
Department of Justice and Attorney-General
Blue Card Services
2
DJAG 039.V3 MAR19
Fax
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
Lawyer
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
D D M M Y Y Y Y
Privacy Notice
The Department of Justice and Attorney-General (DJAG) is collecting your personal information under the Working with Children (Risk
Management and Screening) Act 2000 (WWC Act). Where relevant, DJAG will disclose personal information to organisations you work
for or provide services to about whether you have a current application for, or hold a current blue/exemption card; the outcome of this
application which may include its withdrawal or negative notice, or if your blue/exemption card is subsequently suspended or cancelled.
DJAG publishes confirmation about whether your blue card is valid. DJAG will use and disclose your personal information to assess your
application for a blue/exemption card and will disclose your personal information to courts, law enforcement agencies, disciplinary or
supervisory bodies or anyone you have agreed for DJAG to discuss your application with. It may also be used to contact you with more
information about your application and the Blue Card process. DJAG may use electronic communication for matters of information
provision and collection of data for research purposes. Authorised users of the home-based care register, kept pursuant to the WWC Act,
may also have access to your personal information. DJAG manages your personal information in accordance with the WWC Act and the
Information Privacy Act 2009.
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
www.bluecard.qld.gov.au
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Confirmation Of Identity Valid Until 31 MARCH 2020 (James Cook University of North Queensland)

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Completed 26 July 2020

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