Fillable National Police Check Application PD267 (Services Australia)

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National Police Check Application PD267 (Services Australia)

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The National Police Check Application PD267 (Services Australia) form is 4 pages long and contains:

  • 2 signatures
  • 35 check-boxes
  • 67 other fields

Country of origin: AUSTRALIA
File type: PDF

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Services Australia, (previously DHS - Department of Human Services) is responsible for delivering services relating to health and welfare of Australian citizens. It processes payment of child support other services.

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PD267
NATIONAL POLICE CHECK APPLICATION
Enquiries to Information Services Branch:
(T) 08 7322 3347 (E) SAPOL.NSS@police.sa.gov.au
(A) GPO Box 1539 Adelaide SA 5001
Revised: 9/03/2021
Page 1 of 4
Refer to PD267A – National Police Certificate Frequently Asked Questions before completing this form
Please print clearly in BLOCK letters with black or blue ink.
*Denotes Mandatory Field
CURRENT NAME*
Surname/Family Name Single name only
Given Name(s)
Middle Name(s)
PREVIOUS/OTHER NAME(S)* (Note: if you have more than one previous name or alias, please complete Page 2)
Maiden
Previous
Alias
Single name only
Surname/Family Name
Given Name(s)
Middle Name(s)
BIRTH DETAILS*
Date of Birth: (DD/MM/YYYY)
Gender:
Male
Female
Intersex
PLACE OF BIRTH: Town/City
State
Country
ADDRESSES*
Note: National Police Certificates cannot be posted to an international address.
CURRENT RESIDENTIAL ADDRESS:
Suburb/Town
State
Postcode
POSTAL ADDRESS: (If different to your Current Australian Residential Address)
Suburb/Town
State
Postcode
PREVIOUS ADDRESS:
Suburb/Town
State
Postcode
South Australia Police
NATIONAL POLICE CHECK APPLICATION
PD267
Revised: 9/03/2021
Page 2 of 4
ADDITIONAL PREVIOUS/OTHER NAME(S)
Maiden
Previous
Alias
Surname/Family Name
Given Name(s)
Middle Name(s)
Maiden
Previous
Alias
Surname/Family Name
Given Name(s)
Middle Name(s)
Maiden
Previous
Alias
Surname/Family Name
Given Name(s)
Middle Name(s)
Maiden
Previous
Alias
Surname/Family Name
Given Name(s)
Middle Name(s)
Maiden
Previous
Alias
Surname/Family Name
Given Name(s)
Middle Name(s)
South Australia Police
NATIONAL POLICE CHECK APPLICATION
PD267
Revised: 9/03/2021
Page 3 of 4
CONTACT DETAILS*
Home Telephone
Work Telephone
Mobile Telephone
Email Address
DRIVERS LICENCE/PROOF OF AGE CARD
Drivers Licence/Proof of Age Card No.
State or Country
NATIONAL POLICE CHECK DETAILS*
Are you working or volunteering with children?
Yes, but my employer requires a National Police Check (NPC) in conjunction to my Working With Children Check
issued by Department of Human Services (DHS).
No.
Under law, you must apply through Department of Human Services for a Working With Children Check (WWCC) if you
are working or volunteering with children. An NPC is strictly supplementary.
Will you have contact with Vulnerable Groups?
Please only select one box.
If you will have both unsupervised and supervised contact with vulnerable groups, please select ‘unsupervised’ contact only.
Yes. I will have unsupervised contact with vulnerable groups.
Yes. I will have supervised contact with vulnerable groups.
No. I will not have any contact with vulnerable groups.
Vulnerable groups are defined as:
a)
an adult who is:
(i)
Disadvantaged or in need of special care, support, or protection because of age, disability, or risk
of abuse or neglect, or
(ii)
Accessing a service provided to disadvantaged people
b)
a child aged under 18 years.
Are you applying for a visa?
Yes, to work/travel outside of Australia.
Refer Question 4 & 5 on PD267A – National Police Certificate Frequently Asked Questions
Note: For any other visa contact Australian Federal Police for a National Federal Police Check. South Australia Police cannot process
these requests.
No.
CHECK TYPE
Individual (I)
Individual Concession (IC)
VOAN Volunteer (VC) (No Fee)
Volunteer (VP)
REASON FOR CHECK (maximum length 65 characters)
What is the specific reason for your check?
Proposed Place of Work (Name of Organisation or Type or Workplace)
Location of Employment (Town and State/Territory, or Country if Not Australia)
FINGERPRINTS
Livescan Fingerprints required (additional fee)
Livescan Reference No.:
Wet/Ink Fingerprints required (additional fee)
Note:
NPC and Fingerprints must be paid for together.
Livescan Reference Number must be recorded above.
Refer PD267A – National Police Certificate Frequently Asked Questions, for Livescan locations.
South Australia Police
NATIONAL POLICE CHECK APPLICATION
PD267
Revised: 9/03/2021
Page 4 of 4
CONSENT*
I certify that the applicant details I have provided on this form are true and correct. I hereby consent to the release of full details of any
person history and any other relevant information including pending charges or outstanding warrants that any Australian State / Federal /
Territory Police or Law Enforcement Agency may have in its possession with reference to me. I understand this may include any spent
convictions if there is an applicable exclusion under Schedule 1 of the Spent Convictions Act 2009 or any interstate or federal spent or
rehabilitated convictions (however described) under legislation of that State / Territory / Federal jurisdiction.
I discharge and agree to indemnify and hold harmless the State of South Australia, each of the Australian States / Federal / Territory Police
or Law Enforcement Agencies and their employees, servants and agents from and against all claims, demands, actions, law suits,
proceedings, costs and damages whatsoever arising out of, or in any way connected with, the release or use of the information.
Applicant Signature:
Date:
/ /
Guardian Signature:
Date:
/ /
(if applicant is under 16 years of age)
VOLUNTEER AUTHORITY – Appropriate Section Must Be Completed By Organisation
VOAN (Volunteer Organisation Authorisation Number)
I declare the applicant named on this form is an unpaid VOAN volunteer and the fee is to be paid by the South Australian Government:
VOAN:
Organisation:
Date:
/ /
Authorised Officer’s Name:
Position:
Authorised Officer’s Signature:
Phone No.:
- - - OR - - -
VOLUNTEER (Reduced Fee)
(For unpaid work for an organisation without a Volunteer Organisation Authorisation Number - VOAN)
I declare the applicant named on this form is an unpaid volunteer and the fee is eligible to pay the reduced fee:
Volunteer Organisation:
Date:
/ /
Authorised Officer’s Name:
Position:
Authorised Officer’s Signature:
Phone No.:
PROOF OF IDENTITY (100 Point ID – at least one form of ID from Category A required)
The applicant is required to present original ID documents for certification. A photocopy of the documents must be cited and stapled to
this application form.
CATEGORY A
POINT
VALUE
CATEGORY B
POINT
VALUE
Passport (current or expired
within 2 years but not cancelled)
Birth Certificate (not Extract)
Citizenship Certificate
70
Public Service Employee ID Card
Tertiary Education ID Card
Firearms Licence
Centrelink Card
Veteran Affairs Gold Card
Security Licence (CBS)
40
Mortgage Documents
Land Title Records
35
Drivers Licence (including
foreign licence) (current or
expired within 2 years)
Proof of Age Card
40
Medicare Card
Council Rates Notice
Insurance Renewal
(not Health Insurance)
Bank Statements (cannot be used if
Credit/Bank/Debit card is from same
account)
Bank/Credit/Debit Cards (maximum
two cards from different institutions)
Motor Vehicle Registration
Seniors Card
(not a concession card)
Electoral Enrolment Card
Rent Records (< 6 months old)
Proof of name Change
(e.g. Deed Poll, Marriage Certificate)
Utility account
(only one < 6 months old)
25
Value of Points =
AUTHORISATION
SAPOL Employee Justice of the Peace Commissioner For Taking Affidavits (please tick)
I have witnessed the applicant’s signature and am satisfied as to the correctness of the applicant’s identity as per the attached
certified identification documentation.
Name:
ID No.:
Signature:
SAPOL
or JP
STAMP
HERE
Date:
/ /
Fee Paid: (if applicable)
$
Receipt No.:
Please return authorised PD267 form to VOAN applicants for endorsement by VOAN organisation.
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National Police Check Application PD267 (Services Australia)

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Completed 13 April 2021

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