2
DJAG 008.V3 APR18
Applicant’s name
Part E – Cardholder/applicant's declaration
I declare that:
• the details provided in this form are true and correct;
• I understand it is an oence to provide a false or misleading
statement or document;
• I am proposing to start or continue in regulated employment;
• I am not entitled to an exemption; and
•
I understand that I must notify Blue Card Services within
14 days if I change my name, contact details, or my child-related
employment ends.
Signature of applicant/cardholder
Full name of applicant/cardholder
Date of signature
Part F – Organisation/employer declaration
I declare that:
• the details provided in this form are true and correct;
• I understand it is an oence to provide a false or misleading
statement or document;
• I am authorised to submit this form on behalf of the
organisation;
• the blue/exemption card holder/applicant is proposing to start
or continue in regulated employment with the organisation
listed in Part C;
• an exemption does not apply;
• I have either:
checked the name, date of birth and signature details
provided in this form and confirmed they match those on
the identification documents sighted; or
delegated this responsibility to a prescribed person and
have attached the ‘Confirmation of identity’ form.
Signature of representative
Name of representative
Position of representative
Date of signature
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. 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. DJAG manages your personal information in accordance with the Information
Privacy Act 2009.
D D M M Y Y Y Y
D D M M Y Y Y Y
Application lodgement
Applications may be lodged by one of the following methods:
U
Scan and upload
www.bluecard.qld.gov.au/uploadform
By post
PO Box 12671, Brisbane George Street QLD 4003
In person
53 Albert Street, Brisbane QLD 4000
By fax
07 3035 5910
Fax
