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Fillable Printable National Police Check Application - South Australia

Fillable Printable National Police Check Application - South Australia

National Police Check Application - South Australia

National Police Check Application - South Australia

South Australia Police
National Police Check Application
The attached form is an application for a National Police Check with South Australia Police.
- PLEASE READ THE BELOW IMPORTANT INFORMATION BEFORE PROCEEDING -
APPLYING FOR AN AUSTRALIAN VISA FOR IMMIGRATION PURPOSES; OR
SEEKING EMPLOYMENT WITH A COMMONWEALTH GOVERNMENT AGENCY:
If you are applying for an Australian visa for immigration purposes, or seeking employment
with a Commonwealth Government Agency, you MUST apply through the Australian
Federal Police.SAPOL cannot process these applications.
APPLYING TO BECOME AN ACCREDITED PASSENGER VEHICLE DRIVER
E.G. TAXI DRIVER / BUS DRIVER:
If you are applying to become an accredited passenger vehicle driver, e.g. taxi driver
or bus driver, you MUST apply through the Department of Planning, Transport and
Infrastructure Accreditation and Licensing Centre.
SAPOL cannot process these
applications.
PROOF OF NAME CHANGE:
When providing proof of identification under multiple names (including married names,
change of name) you MUST provide proof of name change, otherwise the application
cannot be processed. Examples include: Marriage Certificate,Change of Name
Certificate or Deed Poll.
AliasPreviousMaiden
FemaleMale
Employment/Probity/LicensingWorking with Children/Vulnerable Groups
Access to National Security InformationVisa
Individual (I)Volunteer (VP)
Core Check (CR)Government (EG)
Individual Concession (IC)
VOAN Volunteer (VC)
CATEGORY*
CHECK TYPE*
South Australia Police
National Police Check Application
Please use blue or black pen and print clearly in BLOCK letters. *DENOTES MANDATORY FIELD
Enquiries: Information Services Branch (T) 08 7322 3347
-
GPO Box 1539 AdelaideSA 5001
APPLICANT DETAILS
Family Name*
First Given Name*
Other Family Name
Other GivenName(s)
Specify Other Name Type Note: if you have more than one previous name,
list on a separate sheet and attach to application
Other GivenName(s)First Given Name
Current Residential Address*
Suburb/TownStatePostcode
PostcodeStateSuburb/Town
Postal Address
(NPC will be posted to this address)
PostcodeStateSuburb/Town
Previous Address
Birth Place - Town/City*
Country*State*
Mobile TelephoneWork TelephoneHome Telephone
Date of Birth* (DD/MM/YYYY)StateDriver's Licence No.
PURPOSE OF CHECK / OCCUPATION:
Type of work must be clearly stated e.g. Aged Carer, Youth Leader, Contractor in Schools.
Generic descriptions i.e. 'Employment', 'Work', 'Uni Placement' are NOT accepted.
FINGERPRINTS
(Only Livescan prints accepted)
Livescan Fingerprints required (additional fee)
Gender*
PD267
Page 1 of 2Revised: 21/11/2014
//
Livescan Reference Number:
NPC and Fingerprints must be paid for together.
Livescan Reference number must be recorded on this form.
Refer NPC FAQ's for Livescan locations and additional Fingerprint information.
Driver's Licence
(including
foreign licence) (current or
expired within 2 yrs)
40
/ /
SAPOL
or JP
STAMP
HERE
- - - OR - - -
/ /
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 includingpending charges or outstanding warrants that any Australian State / Federal /
Territory Police or Law Enforcement Agency may have in its possession with reference to me. This includes any spent or rehabilitated
convictions (however described) under State / Territory / Federal Legislation.
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 anddamages whatsoever arising out of, or inanywayconnectedwith, 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 Number:
VOLUNTEER
(Reduced Fee)
I declare the applicant named on this form is an unpaid volunteer and is eligible to pay the reduced fee:
Volunteer Organisation:
Date:
/ /
Authorised Officer's Name:
Position:
Authorised Officer's Signature:
Phone Number:
PROOF OF IDENTITY (100 Point ID - at least one form of ID from CategoryArequired)
Applicant to present original ID documents + photocopy for certification. Please provide ID in one name otherwise proof of name
change is required (i.e. Marriage Certificate, Deed Poll).
AUTHORISATION: SAPOL EMPLOYEE JUSTICE OF THE PEACE (Tick appropriate box)
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:
Signature:
ID Number:
Date:
/ /
Fee Paid:
(if applicable)
$
Receipt Number:
Please return authorised PD267 form to VOAN applicants for endorsement by VOAN organisation.
Revised: 21/11/2014Page 2 of 2
CATEGORY A
CATEGORY B
POINT
VALUE
POINT
VALUE
70
40
35
25
Passport
(current or expired
within 2 yrs but not cancelled)
Birth Certificate
(not Extract)
Citizenship Certificate
Public Service Employee ID Card
Tertiary Education ID Card
Firearms Licence
Centrelink Card
Veteran Affairs Gold Card
Security Licence (CBS)
Mortgage DocumentsLand Title Records
Proof of Age Card
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
Electoral Enrolment Card
Rent Records (< 6 months old)
Proof of name Change
(e.g.
Deed Poll, Marriage Certificate)
Value of Points =
Utility Accounts
(only one
< 6 months old)
PD267
(Cheques made payable to 'SA Police')
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