2
DJAG 008.V2 JUN17
Applicant’s name
Part F – 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;
• 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include whether my application is withdrawn, or a negative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/exemption card
obligations as a blue/exemption card applicant/cardholder; and
• I consent to confirmation of the validity of my card being
published or provided.
Signature of applicant/cardholder
Full name of applicant/cardholder
Date of signature
Part G – 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 D;
• 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 Working with Children (Risk Management and Screening) Act 2000 allows the collection of personal information to assess your
eligibility to be issued with a blue/exemption card. Information will be provided to Queensland Police, and may be provided to police,
courts, prosecuting authorities or other authorised agencies as part of the screening process. Information may also be given to:
• certain disciplinary bodies to obtain relevant disciplinary information; and/or
• your employer, any supervisory body, or other person you have authorised to discuss your application on your behalf.
Personal information will only be provided to other persons or agencies with your permission or where required by law.
For more information about the blue card system and your obligations go to www.bluecard.qld.gov.au.
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
