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1 Version 4.0
Australian Criminal Intelligence Commission
UNCLASSIFIED
Information about this form
Terms used in this form
Nationally coordinated
criminal history check
Describes both: the checking process
undertaken by the ACIC and police, and the
result received by the accredited body.
Commonly known as a ‘police check’.
You/the applicant
Individual seeking a nationally
coordinated criminal history check.
Accredited body
Organisation accredited with the ACIC
and responsible for submitting your
nationally coordinated criminal history
check.
Australian Criminal
Intelligence Commission
(ACIC)
Australian Government agency responsible
for facilitating access to nationally
coordinated criminal history checks.
Legal entity customer
Organisation the accredited body may use
to collect your application, including your
informed consent. This may be your
employer, benefits provider or issuing body.
Third party
Organisation the accredited body is
required by law to disclose your
personal information and police
information to.
Personal information
Information about you, including any
information contained in your identity
documents.
Police information
Information released as part of a nationally
coordinated criminal history check.
Who completes this form?
Accredited body
The accredited body or its legal entity customer pre-populates this
form with information in these sections: How to submit this form,
Contact details and question D1.
Applicant
You are required to provide your personal details and informed
consent to complete this form. You must also provide your identity
documents, as detailed in Documents required. If you are less than
18 years of age, this form must be completed by your parent or
legal guardian. You are completing this form to obtain a nationally
coordinated criminal history check.
What is a nationally coordinated criminal history
check?
A nationally coordinated criminal history check is conducted with
your informed consent to determine your suitability for
employment, a position of trust or as required by legislation. A
nationally coordinated criminal history check contains your personal
information, and any relevant police information about you,
according to the purpose of your nationally coordinated criminal
history check.
Privacy notice
How will my information be used?
The ACIC and Australian police agencies
The ACIC and Australian police agencies use the information on
this form and the applicant’s identity documentation:
to disclose police information relating to you, to the
accredited body named in question D1.
to update records held about you
for law enforcement, including purposes set out in the
Australian Crime Commission Act 2002 (Cth)
Accredited body
The accredited body or its legal entity customer uses the personal
information collected in this application to request a nationally
coordinated criminal history check and to assure itself of your
identity.
The accredited body may have a legislative basis for the
collection, use and disclosure of your personal information and
police information to a third party. If applicable, third parties are
listed in question D1. The ACIC recommends you seek more
information about relevant legislation from the accredited body.
The accredited body or its legal entity customer must advise you if
your personal information or police information will be
transferred or supplied to a location outside Australia, known as
the permitted offshore transfer arrangement. If this applies, the
legal name and location of the overseas entity are listed in
question D1. The ACIC recommends you seek more information
from the accredited body listed in D1.
You can contact the accredited body for more information on how
they handle your personal information using the contact details at
the end of this section.
How is my national coordinated criminal history
check result determined?
Police information is disclosed in accordance with applicable
spent conviction legislation and information release policies of the
Australian Government and state and territory governments.
These links may help you source information on spent convictions:
Australian Government www.legislation.gov.au
Australian Capital Territory www.legislation.act.gov.au
New South Wales www.legislation.nsw.gov.au
Northern Territory www.legislation.nt.gov.au
Queensland www.legislation.qld.gov.au
South Australia www.legislation.sa.gov.au
Tasmania www.thelaw.tas.gov.au
Victoria www.police.vic.gov.au
Western Australia www.legislation.wa.gov.au
NATIONALLY COORDINATED CRIMINAL HISTORY CHECK | MODEL APPLICATION AND INFORMED CONSENT FORM
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Australian Criminal Intelligence Commission
UNCLASSIFIED
How do I dispute my result?
If you do not agree with the results of your nationally coordinated
criminal history check, contact the accredited body or, if
applicable, its legal entity customer, using the contact details on
page 3 and tell them you want to dispute the result. The
accredited body or its legal entity customer accepts and escalates
all disputes.
Providing incomplete, false or misleading information
You must take reasonable steps to ensure you provide accurate,
complete and up-to-date personal information. Withholding
and/or providing misleading, or false information on this form is a
Commonwealth offence and you may be prosecuted under the
Criminal Code Act 1995 (Cth).OW TO
If you become aware you have provided incorrect information you
must contact the accredited body as soon as possible.
Documents required
Minimum identity requirements
You must provide four documents with your completed form to
confirm your identity:
• one commencement of identity document to confirm your
birth in Australia or arrival in Australia
• one primary use in the community document to show the
use of your identity in the community; and
• two secondary use in the community documents
The accredited body or its legal entity customer will use these
documents to verify your identity with the personal information you
have provided on this form. The personal information contained in
your identity documents will be used to conduct a nationally
coordinated criminal history check, as you consent to in Section D.
The documentation you provide must include evidence of your full
legal name, date of birth and a photograph of you. If a photograph
is not provided on the identity documents presented, a passport-
style photograph certified by a person listed in Schedule 2 of the
Statutory Declaration Regulations 2018 can be accepted in addition
to the four required documents.
Commencement documents
(a) full Australian birth certificate (not an extract or birth
card)
(b) current Australian passport (not expired; however, if the
Document Verification System (DVS) is used to verify the
passport, it may be up to 2 years expired)
(c) Australian visa current at time of entry to Australia as a
resident or tourist *
(d) ImmiCard issued by Department of Home Affairs
(previously the Department of Immigration and Border
Protection) that enables the cardholder to prove their visa
and/or migration status and enroll in services
(e) certificate of identity issued by Department of Foreign
Affairs and Trade (DFAT) to refugees and non-Australian
citizens for entry to Australia
(f) document of identity issued by DFAT to Australian
citizens or persons who have the nationality of a
Commonwealth country for travel purposes
(g) certificate of evidence of resident status.
(h) Australian Citizenship Certificate.
* A Visa Entitlement Verification Online (VEVO) record may be
provided. If you are a New Zealand citizen on a Special Category Visa,
you can request your VEVO details from the Department of Home
Affairs via their website.
Primary documents
a) current Australian drivers licence, learner permit or
provisional licence issued by a state or territory, showing a
signature and/or photo and the same name as claimed
b) Australian marriage certificate issued by a state or
territory (church or celebrant-issued certificates are not
accepted)
c) current passport issued by a country other than Australia
with a valid entry stamp or visa
d) current proof of age or photo identity card issued by an
Australian Government agency in the name of the
applicant, with a signature and photo
e) current shooters or firearms licence showing a signature
and photo (not minor or junior permit or licence)
f) for persons under 18 years of age with no other Primary
Use in Community Documents, a current student
identification card with a signature or photo.
Secondary documents
a) certificate of identity issued by DFAT
b) document of identity issued by DFAT
c) convention travel document secondary (United
Nations) issued by DFAT
d) foreign government issued documents (for example,
drivers licence)
e) Medicare card
f) enrolment with the Australian Electoral
Commission
g) security guard or crowd control photo licence
h) evidence of right to an Australian government
benefit (Centrelink or Veterans’ Affairs)
i) consular photo identity card issued by DFAT
j) photo identity card issued to an officer by a police
force
k) photo identity card issued by the Australian Defence
Force
l) photo identity card issued by the Australian
Government or a state or territory government (this
may take the form of a Working with Children or
Vulnerable People card or a government issued
occupational licence)
m) Aviation Security Identification Card
n) Maritime Security Identification card
o) credit reference check
p) Australian secondary or tertiary student photo
identity document
q) certified academic transcript from an Australian
university
r) trusted referees report
s) bank card, credit card or bank statement (without
recording the payment card number/s)
t) state/territory government rates assessment notice
or Australian Taxation Office assessment notice
u) Australian utility bill showing name and address
v) Australian Private Health Insurance Card
w) Australian Trade Association card.
Names
All names under which you have been or are currently known will
be included on the nationally coordinated criminal history check.
If you are concerned about the disclosure of details relating to your
previous known names, please contact the accredited body through
which you are submitting your check for a nationally coordinated
criminal history check for assistance.
NATIONALLY COORDINATED CRIMINAL HISTORY CHECK | MODEL APPLICATION AND INFORMED CONSENT FORM
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UNCLASSIFIED
Change of name
If you provide identity documents using a former name, you must
provide evidence of your name change. This means providing a
change of name certificate issued by the Australian Registry of
Births, Deaths and Marriages or an Australian marriage certificate
issued by a state or territory, in addition to your four identity
documents. Church or celebrant-issued certificates are not
accepted.
Special provisions for proof of identity
The ACIC recognises that in exceptional circumstances you may not
be able to meet the minimum proof of identity requirements.
Please contact the accredited body who will assess your ability to
meet the requirements and determine the most suitable method
to confirm your identity.
How to submit this form
Before submitting this form, ensure all sections are complete and
that you have signed and dated the form.
Submit your completed form and identity documents using these
instructions:
Contact details
You can contact the accredited body or its legal entity customer for
more information on the nationally coordinated criminal history
check process, how your personal information is handled and how
you can dispute your result.
Accredited body
Contact details
Legal entity customer (if applicable)
Contact details
Section A – Personal information
A1. Please read this before answering the following questions.
You must disclose all names you have been known by throughout
your life, including your full legal name, name before marriage
(maiden name), and other previous names and/or alias names.
All names that you submit as part of your nationally coordinated
criminal history check, will appear on the check result. If you are
concerned about the disclosure of previous name, please contact
the accredited body.
With each additional name you provide, you must include your
family name, first given names and other given names (if
applicable).
Example:
When Lucianne was born, she was given the first name Lucianne,
second given name Jane and surname of Jones. When she was
married, she changed her surname to Smith. Lucianne commonly
uses the name Lucy when introducing herself in the community.
As such, Lucianne has four known names—her current name,
maiden name, the alias name she used before she got married and
the alias name she uses now. Lucianne needs to provide all four
names when completing this form, as follows:
Current name: Smith, Lucianne Jane
Maiden name: Jones, Lucianne Jane
Alias name: Smith, Lucy Jane
Previous name: Jones, Lucy Jane
Full legal name
Family name
First given name(s)
Other given name(s)
Previous known name (if applicable)
Family name
First given name(s)
Other given name(s)
Name Type Maiden
Alias
Previous
Previous known name (if applicable)
Family name
First given name(s)
Other given name(s)
Name Type Maiden
Alias
Previous
📎
If more room is required, please list on a separate
sheet, sign and attach to this form.
Additional sheet attached? Yes
No
A2. Please read this before answering the following question.
You must select the gender that best describes how you
identify yourself within the community.
The gender details that you submit as part of your nationally
coordinated criminal history check, will be the gender that
appears on the check result.
NATIONALLY COORDINATED CRIMINAL HISTORY CHECK | MODEL APPLICATION AND INFORMED CONSENT FORM
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UNCLASSIFIED
The ACIC’s processes are aligned with the Australian
Government Guidelines on the Recognition of Sex and
Gender. If these Guidelines affect you and you would like
additional information specifically regarding this, please
contact the ACIC directly at npcs@acic.gov.au
Your gender
M
(Male)
F
(Female)
X
(Indeterminate/intersex/unspecified)
A3. Please read this before answering the following questions.
If you cannot provide all these details, contact the
accredited body or its legal entity customer.
Your date of birth
Your place of birth
Suburb/town
State/territory
Country
A4. Please read this before answering the following questions.
Provide your current and previous residential addresses for
the past five years.
If you cannot provide full details, provide as much information
as possible. If you are unsure how to complete this section
contact the organisation that gave you this form.
Current residential address
Street address
Suburb/town
State/territory
Postcode
Country
Dates residing at address:
From
/ /
Previous residential address 1
Street address
Suburb/town
State/territory
Postcode
Country
Dates residing at address:
From
/ /
To
/ /
Previous residential address 2
Street address
Suburb/town
State/territory
Postcode
Country
Dates residing at address:
From
/ /
To
/ /
Previous residential address 3
Street address
Suburb/town
State/territory
Postcode
Country
Dates residing at address:
From
/ /
To
/ /
📎
If more room is required, please list on a separate
sheet, sign and attach to this form.
Additional sheet attached? Yes
No
A5. Please read this before answering the following questions.
If you have an Australian drivers licence and/or an
Australian firearms licence, you must provide the licence
number and the state or territory that issued your licence.
If you have a foreign drivers licence and/or a firearm licence
you must provide the licence number and the country that
issued your licence.
If you have a passport, you must provide the passport
number and the country that issued your passport.
Drivers licence number (if available)
Issued by (state/territory)
Firearm licence number (if available)
Issued by (state/territory)
Passport number (if available)
Issued by (country)
/ /
NATIONALLY COORDINATED CRIMINAL HISTORY CHECK | MODEL APPLICATION AND INFORMED CONSENT FORM
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UNCLASSIFIED
Section B - Purpose of the nationally
coordinated criminal history check
The purpose for your nationally coordinated criminal history check
helps determine what police information is disclosed on your result.
B1. Please read this before answering the following question.
For question B1, provide the following information:
1. position title, occupation, volunteer role or entitlement
being sought
2. proposed place of work (name of organisation or type of
workplace or industry)
3. location of the role (town and state/territory)
Acronyms must not be used – except for the state/territory.
Example: Case worker, Youth Housing Facilities, Canberra,
ACT.
Example: volunteer in canteen, St Bebes, Canberra, ACT
Your position title, occupation, volunteer role or entitlement
Your proposed place of work (name of organisation or type of
workplace or industry)
The location of your work (town and state/territory)
B2. Please read this before answering the following question.
For question B2, indicate whether you will have
supervised/unsupervised contact with vulnerable groups as
part of the role you are applying for.
Vulnerable groups means:
- a child,
- an adult who is disadvantaged or in need of special
care, support or protection because of age, disability or
risk of abuse or neglect.
Contact means direct or indirect face-to-face contact,
phone contact or any type of communication over the
internet.
Supervision means in the presence of an adult who is
responsible for the safety or care of the vulnerable person.
Unsupervised means you will not be in the presence of an
adult who is responsible for the safety or care of the
vulnerable person.
Select the statement that best describes the role you are
applying for:
Supervised contact with vulnerable people
Unsupervised contact with vulnerable people
No contact with vulnerable people
Section C – Type of nationally coordinated
criminal history check
C1. Please read this before answering the following question.
You may request a volunteer check if you will hold a position
or perform a role where you will not receive any salary,
benefits or financial gain. This includes students undertaking
compulsory vocational placements.
Volunteer check type must not be selected for the
Australian Government’s Work for the Dole Scheme.
You must be able to validate the charity organisation or
volunteer position to support your selection of the
volunteer type.
What is the check type?
Standard
Volunteer
Section D – Informed consent
What is informed consent?
Your informed consent is needed before an accredited body can
request a nationally coordinated criminal history check for you.
Your informed consent means you:
have read and understood the information provided in this
form about how your personal information and any police
information relevant to you will be handled and disclosed
provide your permission for the accredited body to request a
nationally coordinated criminal history check on your behalf
provide your permission for the accredited body to disclose
your information to any organisation listed in D1 of this form.
How do I provide my informed consent?
An important aspect of providing informed consent is that you
understand what you are consenting to. It is important that you
read the consent statements in question D2 and, where required,
get clarification from the accredited body or its legal entity
customer, to ensure complete understanding. You must then sign
and date this form at D2, to give your informed consent.
Important: Please read this information about question D1.
The accredited body is required to complete the details at D1
before providing the form to you.
D1 provides the details of the organisations to whom your
personal and police information will be disclosed to.
In question D2, you will provide your informed consent for your
personal and police information to be disclosed to the ACIC,
Australian police agencies, law enforcement agencies, and any
organisations detailed in question D1.
D1. Organisations to whom the applicant’s personal and police
information will be disclosed
Accredited Body
Accredited body (legal name)
Address
NATIONALLY COORDINATED CRIMINAL HISTORY CHECK | MODEL APPLICATION AND INFORMED CONSENT FORM
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UNCLASSIFIED
Preferred contact details
ABN
Legal entity customer or related government entity
Legal entity customer or related government entity (legal
name)
Address
Preferred contact details
ABN
Third parties (as required by law)
Third party 1 (legal name)
ABN
Third party 2 (legal name)
ABN
Permitted offshore transfer arrangements
Overseas entity (legal name)
Location (Country)
📎
If more room is required, please list on a separate
sheet, sign and attach to this form.
Additional sheet attached? Yes
No
D2. Please read this before answering the following question.
You must provide your name, read each statement carefully
and then print your name, sign and date to provide your
informed consent.
Applicant’s consent to submit a nationally coordinated
criminal history check
I,
Family name
First given name(s)
Other given name(s)
1. acknowledge that I/the applicant understand the
information on this form.
2. acknowledge that the accredited body named in D1 is
collecting information in this form to provide to the
Australian Criminal Intelligence Commission (ACIC) and
police agencies, for a nationally coordinated criminal
history check to be conducted for the purpose outlined in
Section B of this form.
3. have fully and accurately completed this form, and the
personal information I/the applicant, have provided
relates to me/the applicant, and contains the full name
and all names previously used by me/the applicant.
4. acknowledge that withholding and/or providing
misleading or false information on this form and in any
supplied identity documents is a Commonwealth offence
and may lead to prosecution under the Criminal Code Act
1995 (Cth).
5. acknowledge that personal information that I/the
applicant provided on this form and on the supplied
identity documents may be disclosed to the accredited
body named in Section D of this form (including
contractors, legal entity customers, related bodies or third
parties named in D1 of this form in Australia or overseas,
if applicable).
6. acknowledge that any information sent by mail or
electronically, in relation to this form, including identity
documents, is sent at my/the applicant’s risk and I/the
applicant, am aware of the consequences of sending
information in these ways.
7. acknowledge that I/the applicant am aware that I/the
applicant am providing consent for a nationally
coordinated criminal history check to be conducted using
all personal information provided in this form and
provided in suppled identity documents.
8. understand and consent to police information relating to
me/the applicant, being disclosed in accordance with the
purpose identified in Section B of this form, and applicable
legislation and information release policies (including
spent convictions legislation described in Australian
Government and state or territory legislation).
9. give consent to:
a. the ACIC and police agencies using and disclosing
my/the applicant’s personal information that I/
the applicant, have provided in this form and
personal information contained in my supplied
identity documents to conduct a nationally
coordinated criminal history check.
b. the ACIC disclosing the police information sourced
from the police agencies to other approved bodies
and the accredited body named in D1 of this form.
c. the accredited body named in D1 of this form
disclosing to the legal entity customer, third
parties and any permitted offshore transfer
arrangements also detailed in D1, my/the
applicant’s personal information and police
NATIONALLY COORDINATED CRIMINAL HISTORY CHECK | MODEL APPLICATION AND INFORMED CONSENT FORM
7 Version 4.0
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UNCLASSIFIED
information to assess my/the applicant’s suitability
for the purpose identified in Section B of this form.
10. acknowledge that it is usual practice for my/the
applicant’s personal information and police information
to be used by police agencies and the ACIC for law
enforcement, including purposes set out in the Australian
Crime Commission Act 2002 (Cth).
Applicant
Print name
Signature
Date
/ /
Parent or legal guardian
(where the applicant is under the age of 18)
Print name
Signature
Date
/ /
Authorised agent
(person responsible for the applicant, such as a legal
representative)
Print name
Signature
Date
/ /
Section E - Office use only
Accredited body or its legal entity customer declaration.
E1. What is the nationally coordinated criminal history check
category for this check?
For example: Employ/probity/licence.
E2. Collected Identity Documentation
1) Commencement of identity document:
Type of document collected:
Name as it appears on the identity document:
Document identifier number:
2) Primary use in the community document:
Type of document collected:
Name as it appears on the identity document:
Document identifier number:
3) Secondary use in the community document:
Type of document collected:
Name as it appears on the identity document:
4) Secondary use in the community document:
Type of document collected:
Name as it appears on the identity document:
5) Change of name document (if applicable):
Type of document collected:
Previous name as it appears on the document:
Current name as it appears on the document:
E3. The accredited body or its legal entity customer declares that:
The correct check type has been selected for this check
and they have verified the legitimacy of this claim.
They are satisfied as to the applicants’ identity and have
verified the linkage between the applicant and the
claimed identity.
Staff member
Print name
Signature
Date
/ /
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Completed 8 May 2021

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