2
DJAG 003.V2 JUN17
Applicant’s name
1 Title Mr Mrs Miss Ms
Other
2 Full legal name
Family name
First name
Middle name
No middle name (please tick)
3 Do you have a previous name, or have you been known
by any other name?
Yes
(record details below) No
It does not matter how long ago you used the name
or how long the name was used for e.g.
• birth name • name before marriage • married name
• alias • change by certificate • adoption
• changed order of name
Family name
First name
Middle name
If you require more space, please tick this box
and attach a separate list.
4 Gender
5 Date of birth
6 Place of birth
Town/City
State/Territory
Country
7 Current postal address (within Australia)
Postcode
8 Current residential address (if different to above)
Postcode
9 Telephone number
Daytime
Mobile
10 Email
11 Do you identify as? (if applicable)
Aboriginal Torres Strait Islander
Aboriginal and Torres Strait Islander
12 Previous blue/exemption card number (if applicable):
/
13 Are you, or have you ever been a: (please tick)
Foster or kinship carer
Health practitioner
Operator/supervisor/carer of a child care
or education service
Teacher
14 Applicant’s declaration
I declare that:
• I am the applicant named in this form and have not
omitted any names or aliases that I use or have used
in the past;
• the information and identification documents provided
by me for this application are true and correct and I
understand it is an oence to provide a false or misleading
statement or document;
• I consent to information from any police, court,
prosecuting authority or other authorised agency being
obtained and for the police, courts, prosecuting authority
or other authorised agency to disclose any information
for the purposes of assessing my eligibility to work with
children including ongoing checks while my application/
exemption card remains current;
• I understand that the information obtained includes but is
not limited to details of convictions
^
and pending or non-
conviction charges
*
or information on the circumstances
relating to oences committed or allegedly committed by
me, regardless of when and where the oence or alleged
oence occurred;
• I am a registered teacher or police ocer proposing
tostart or continue in regulated employment and
am notentitled to an exemption on the basis of that
regulatedemployment;
• I understand my organisation will be advised whether or
not I have a current application for, or hold a current blue/
exemption card; the outcome of this application which
may include whether my application is withdrawn, or a
negative notice issued, or if my blue/exemption card is
subsequently suspended or cancelled;
• I understand and will comply with my blue card
obligations as an exemption card applicant/
cardholder; and
• I consent to the confirmation of the validity of my blue/
exemption card being published or provided.
Sign inside the box.
Please do not touch or go outside the lines.
Date of signature
Part E – Applicant’s details (to be completed by the applicant)
D D M M Y Y Y Y
D D M M Y Y Y Y
