Fillable Printable Criminal History Check Appllication - Northern Territory Police
Fillable Printable Criminal History Check Appllication - Northern Territory Police
Criminal History Check Appllication - Northern Territory Police
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CRIMINAL HISTORY CHECK – APPLICATION
C
APPLICATION FOR CRIMINAL HISTORY CHECK AND CONSENT
TO RELEASE NATIONAL POLICE CERTIFICATE.
Is this a Fingerprint or Name Check only? FINGERPRINT $126 NAME CHECK $52
Is this application for the purpose of volunteering? YES $5 NO
If YES, then Section E must be completed by the volunteering organisation you are registered with.
If this is for a Fingerprint check you must supply your ngerprints with this application. Fingerprints can be taken at NT Police stations by
appointment only. See ‘Applying For Fingerprint Check’ fact sheet on our web page for details.
Title
Mr Mrs Miss Ms Other – please specify
Family name/surname
First given name Other given name/s
Male Female Daytime contact phone number/mobile Date of birth (DD MM YYYY)
/ /
Were you born in Australia? Suburb/town of birth State
Yes Please record your suburb/town/state of birth
City of birth Country of birth
No Please record your city/country of birth
Other names you have used (including former, maiden name/s etc)
If you are known or have ever been known by any other names, please list them below.
Maiden name Former name Also known as Family name/surname
OR OR
First given name Other given name/s
Former name Also known as Family name/surname
OR
First given name Other given name/s
Please attach a separate sheet to list other names that you are currently, or have previously, been known as.
Section A – Details of Applicant (This section must be completed)
Phone 1800 723 368 (1800 SAFENT)
Oce Hours 8•30am–4•30pm Monday–Thursday
9•30am–5•30pm Friday
PF095 06/12
SAFE NT OFFICE USE ONLY
Date Received
/ /
CNI PN
Receipt No CR Form Lodged at
NORTHERN TERRITORY POLICE
SAFE NT
PRINT ALL RESPONSES IN BLOCK LETTERS
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You must enter your current residential address in the space provided. Enter your postal address if it diers from your current residential
address. Your National Police Certicate containing details of your criminal record will be delivered to your current postal address.
Please provide residential addresses for the last 10 years only.
Current residential address (must not be a PO Box or business address)
Unit number/street number/street name Suburb/town/locality State Postcode
Postal Address
Unit number/street number/street name/PO Box Suburb/town/locality State Postcode
Previous Residential Addresses for the last 10 years. Please begin with the most recent not including your current address.
Unit number/street number/street name Suburb/town/locality State Postcode
FROM
/ /
TO
/ /
Country if outside Australia
Unit number/street number/street name Suburb/town/locality State Postcode
FROM
/ /
TO
/ /
Country if outside Australia
Unit number/street number/street name Suburb/town/locality State Postcode
FROM
/ /
TO
/ /
Country if outside Australia
Please attach a separate sheet if you require further space to list other previous residential addresses over the past 10 years.
Section B – Current, postal and previous residential address/es (this section must be completed)
Section C – Purpose of check (this section must be completed)
This section must be completed.
When compiling a National Police Certicate containing your criminal history information, NT Police conduct a national name check. If
information is obtained from other police jurisdictions, the relevant legislation or policy for that jurisdiction, together with that of the
Northern Territory is applied to the information before it is released. The legislation to be applied is determined by the purpose of your
check.
Why do you need a police check? Please select one of the following categories:
Australian citizenship Visa application
Licence requirement Name of licence
Employment check Occupation/title
Provide a brief description of the work you will be doing.
Will you be working with vulnerable people? YES NO See Application guidelines for details
Other Please describe
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Section D – Employer Organisation/Licencing Authority details
If you nominate the original National Police Certicate containing your criminal history information to go to your employer organisation,
or licencing authority, a copy of this document will be sent to your postal address for your records.
Name of employer organisation/licencing authority
Postal address of organisation
Daytime Contact phone number. Name/ Position title of organisation’s representative
Please tick if you require the original results of this check to be sent directly to the organisation listed above
If you nominate the original National Police Certicate containing your criminal history information to go to the organisation that you
will work with as a volunteer, a copy of this document will be sent to your postal address for your records.
Name of organisation
Postal address of organisation
Daytime Contact phone number.
Please tick if you require the original results of this check to be sent directly to the volunteer organisation listed above
To be completed by CEO/Manager of Volunteer Organisation
I certify that the person named on this form is a registered volunteer with this organisation and will receive no payment, benet or
nancial gain from the work that they undertake on our behalf.
Name/position
Signature Date signed
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If you wish to disclose information that is contained on your criminal history, it may assist to expedite the check process. If you have been
charged or convicted of an oence please ll in the details in the space below.
Section E – Details of Volunteer Organisation (this section must be completed by the volunteer organisation you will be working with)
Section F – Self Disclosure of Criminal History
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Section G: Proof of Identity
Proof of identity documentation
Applicants must supply a minimum of two (2) types of acceptable identication from the list below with a minimum of 100 points.
Identication must include at least one type of photo ID (Category A) plus identication that contains the applicant’s current residential
address, signature and date of birth. All documents sighted by the Authorised ocer must be original, or certied copies of an original
document. All documents must be current or valid. Documents that have expired will not be accepted as proof of identity. Once
checked, all documents will be returned to you.
You must also attach a photocopy of one piece of photographic identication to this form. This will not be returned to you.
Category A – you must have at least ONE Category A document Points
1. Current passport (Australian/Foreign) 70
2. Current Australian drivers licence 40
3. Firearms licence 40
4. Current tertiary student ID card with photo 40
5. Australian evidence of age card (18+) 40
6. Photographic ID issued by the Coalition of Indigenous Community Organisations
or the Larrakia Nation Aboriginal Corporation 40
Category B
7. Australian citizenship certicate 70
8. Australian birth certicate 70
9. Centrelink card 40
10. Government employee ID 40
11. Statutory declaration as to identity by a person authorised to verify copies of the
identication documents. 40
12. Medicare card 25
13. Credit/debit card of nancial institution passbook (1 per nancial institution) 25
14. Property rates notice/utilities notice 25
15. Property lease agreement 25
16. Foreign drivers licence 25
17. Bank statement (with residential address) 25
Add total points (must be 100 points or more) TOTAL
Complete the following section with details from two of the documents used to verify your ID. You must include information
from at least one Category A document from the list above, including licence/passport/ID number and expiry date.
Category A document. Please identify document number from list above (1–6).
Passport/licence/ID number
State of Issue Expiry Date
/ /
Country of Issue
Other document provided. Please identify document number from list above (1–17).
This can be a second Category A document.
Card/licence/membership/ID number
State of Issue Expiry Date
/ /
Country of Issue
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Authorised persons use only
Persons authorised to verify documentation are required, in the presence of the applicant, to sight original documentation and verify
that the photographic identication is a true likeness of the applicant. The authorised person needs to complete and sign the declaration
below.
Declaration – by authorised person
• I am a person authorised to be shown identity documents
• I have sighted 100 points or more of ID and certied a photocopy of one form of photo ID for:
Applicant’s given name Applicant’s family name
Name of authorised person
Address Daytime contact number
Number from the list of Authorised people above that most applies to you (1–13).
Current address has been sighted
Signature Date signed
/ /
In certain circumstances of hardship an application may be made to the Screening Authority for the ability to vary the requirement for
meeting 100 points. For further information contact: safent.police@pfes.nt.gov.au
If you are under the age of 18, then one document from Group A or a statutory declaration of identity attesting that you are a current
student of the school made by a Principal of that school will be sucient to satisfy the 100 point check
Section G: Proof of Identity - continued
Persons Authorised to validate identity of the candidate
1. Sta members of SAFENT
2. An Ocer, auxiliary or Aboriginal Community Police Ocer of
the Northern Territory Police Force
3. Sta member of Territory Business Centres
4. Justice of the Peace
5. Legal Practitioner (eg. Barrister or Solicitor)
6. Commissioner for Adavits and Commissioner for Oaths
7. Notary Public
8. Judge or Magistrate appointed to an Australian court
9. Chief Executive Ocer of a local Government body
10. An Ocer of the Police Force of an other domestic or foreign
jurisdiction, at the rank of Sergeant or higher, or the highest
ranking ocer of the Police Station.
11. A registered Medical Practitioner
12. A Sheri in a State or Territory of Australia
13. Other persons authorised by the Screening Authority
See Application guidelines for details.
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Section H: Certication and statement of consent and indemnity (this section must be completed)
Checklist and Payment Options
1. Have you completed all sections of the form?
2. Have you completed the 100 point check?
3. Have you attached a certied copy of your photo ID?
4. Have you attached the appropriate fee?
Application Fees
Name Check for Employment or Licencing Purposes $52
Name Check for Volunteering with an Organisation $5
Fingerprint and Name Check $126
Payment Options
In person to SAFE NT
Ground Floor, 77 Smith Street Darwin
Cash, Cheque/Money Order/Credit Card
Via Mail to SAFE NT
NT Police
PO Box 39764 WINNELLIE NT
Cannot accept cash through mail
Cheque / Money Order
Credit Card (Visa/ Mastercard)
Credit card authorisation
I authorise SAFE NT to process my payment of
$
from my Visa/Mastercard.
Cardholders name
Card Number
Expiry
/ /
Cardholders signature
Contact: SAFE NT
PO Box 39764 WINNELLIE NT 0821
Phone 1800 723 368
www.nt.gov.au/safent
email: safent.polic[email protected].au
I certify that I am the applicant named in this form and all the details provided by me are true and correct. I have not omitted names or
aliases that I have or may have used previously. I have read and understood the contents of this form.
I consent to the release of details of any convictions, or other information, including pursuant to section 15 and section 15A of the
Criminal Records (Spent Convictions) Act 1992, convictions that are otherwise known as ‘spent convictions’, recorded against my name, to
the person and/or organisation listed on this form.
I hereby indemnify the Northern Territory of Australia, its servants and agents including all members of Northern Territory Police
against all liabilities and against all actions, suits, proceedings, claims, demands, costs, and expenses whatsoever which may be taken
or made in respect of the release or use hereunder of any details of any convictions, or other information purporting to either relate to
or involve me.
Name of applicant
Signature Date Signed
/ /
