Fillable Printable Identity Declaration Form - Queensland
Fillable Printable Identity Declaration Form - Queensland
Identity Declaration Form - Queensland
Customer identity declaration • V4 • July 2013 Page 1 of 2
Customer identity declaration
Aboriginal and Torres Strait Islander
This form is eective from 1 July 2013
Instructions
Please use BLOCK letters when completing this form. Attach extra sheets if necessary. All dates should be DD/MM/YYYY.
Privacy statement—please read
The Office of Fair Trading is collecting information, including personal information, on this form for the purposes of verifying your
identity. Where authorised or required by law, information on this form can be disclosed without your consent.
This form should only be used if you are genuinely unable to provide suitable evidence of identity documentation because your
birth has not been registered and
• You are of Aboriginal or Torres Straight Islander descent; or
• You identify as an Aboriginal or Torres Straight Islander and are accepted as such by the community in which you live or
formerly lived,
If you use this form, your application will take longer to process as at least one of the verifying persons must be contacted.
This declaration will be refused if the verifying person can not be contacted during business hours.
0331FT_0713
Part 1—Personal details—please print
Personal details
Family name .....................................................................................................................................
Given name/s ..................................................................................................................................
Other names if applicable (maiden name, community name or traditional name)
.........................................................................................................................................................
Residential address .........................................................................................................................
Suburb .......................................................... State
Postcode
Postal address .................................................................................................................................
Suburb .......................................................... State
Postcode
Aboriginal/Torres Strait community where you reside ......................................................................
Phone
(day time) ............................................. Mobile ...............................................................
Date of birth
Place of birth ....................................................................................................................................
Eye colour ...................................................... Height ................................................................
Hair colour ..................................................... Complexion .........................................................
Part 2—Personal declaration
Sign only in the presence of
one of the verifying persons.
I declare that I have read all the answers I have given to all the questions in this declaration and that
the answers given by me in this declaration are complete, true and correct in every detail.
I understand that if I have stated anything in this declaration that is false or misleading the licence
granted to me as a result of this declaration will be absolutely void and have no legal effect
whatsoever. I authorise the authorising officer to make any enquiries considered necessary to verify
the information provided by me in this declaration.
I understand that I may be prosecuted for giving false or stating any false or misleading information.
Signature ........................................................................... Dated:
Customer identity declaration • V4 • July 2013 Page 2 of 2
Part 3—Verification of identity
Verification of identity
The verifying persons’
declaration must be completed
by two people from the
following list:
• Community Justice
Group chairperson, vice-
chairperson or coordinator
• Community Council
chairperson or Deputy
chairperson
• Community councillor
• Justice of the Peace
or Commissioner for
Declarations
First verifying person’s details
Family name .....................................................................................................................................
Given name/s ..................................................................................................................................
Official position/role .......................................................................................................................
Phone
(day time) ............................................. Mobile ...............................................................
Residential address/community .......................................................................................................
Suburb .......................................................... State
Postcode
Second verifying person’s details
Family name .....................................................................................................................................
Given name/s ..................................................................................................................................
Official position/role .......................................................................................................................
Phone
(day time) ............................................. Mobile ...............................................................
Residential address/community .......................................................................................................
Suburb .......................................................... State
Postcode
Part 4—Verifying persons’ declaration
We, the undersigned, declare that ...................................................................................................
is recognised as being Aboriginal/Torres Straight Islander (cross out option that does not apply)
and normally resides in the Aboriginal/Torres Straight Islander community (cross out option that
does not apply) of .............................................................................................................................
We recognise their claim that their date of birth is
.
We give permission for the authorising officer to contact us for any further information considered
necessary for the purpose of this declaration and agree to give any further information that the
authorising officer may ask for to verify any statement made in this declaration.
We declare that, to the best of our knowledge, the information given by the person making this
declaration is complete, true and correct.
We declare that the information provided by us in this declaration is complete, true and correct in
every details.
First verifying person’s signature .....................................................................................................
Dated:
Second verifying person’s signature ................................................................................................
Dated:
