QP 0349B Application for a Police Certificate Name with Fingerprint Search Page 1 of 2
QUEENSLAND POLICE SERVICE
APPLICATION FOR A POLICE CERTIFICATE
NAME WITH FINGERPRINT SEARCH
Please ensure your Application is fully completed and legible. Failure to supply the requested information
may mean that the QPS is unable to process this form. For ENQUIRIES contact a Client Liaison Officer by
email: firstname.lastname@example.org or phone: (07) 3364 6262.
A Police Certificate based on Australia–wide check of criminal history records using name with fingerprint search.
NOTE: Police Certificates are usually for EMPLOYMENT or OVERSEAS TRAVEL purposes.
Proof of identity—Please ensure a copy of ONE of the following forms of identification is attached to this application:
1. Your current driver licence
Number: Issuing state:
Your current passport –
including photograph and signature Number: Issuing country:
Two other forms of i
dentification bearing your signature
The fingerprints you provide will be compared against the national fingerprint system administered by the CrimTrac Agency—
an Executive Agency of the Commonwealth. This search is part of the nation–wide check of criminal history records.
The Queensland Police Service usually registers fingerprint images on the national fingerprint system together with the applicant’s
name, date of birth and gen
der. Registered fingerprint images and personal details remain as a permanent record on the system.
All Australian police services have access to the system for the performance of their policing functions.
The Queensland Police Service will only permanently register your fingerprint images and de
tails if you consent.
(It is MANDATORY to tick one box.)
I do not consent to my fingerprint images and details being permanently registered on the national fingerprint system
and require them to be destroyed after comparison.
I consent to my fingerprint images and details being permanently registered.
Family name: Given name(s):
Other names you have been known by:
(such as name at birth, alias(es), previous married name(s))
Date of birth:
(DD / MM / YY)
Place of birth: Town: State: Country:
If the Certificate is for overseas travel (visa) purposes, AND IF IT IS REQUIRED TO BE FORWARDED DIRECTLY to the
Consulate of the country to which you are travelling, state FULL name and address of Consulate:
In consideration of the issue and supply of the document requested herein, I hereby undertake and declare that I will not take any action
either civil or criminal against the Commissioner of the Queensland Police Service or Police Service of any other State or Territory of
the Commonwealth of Australia, or of any other country, or authorise or cause or procure or permit any person on my behalf to take
any action concerning anything had or done by them in relation to this application.
Date: DD / MM / YY
(DD / MM / YY)
(Witness signature) (Witness name)