Fillable Printable 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/Licensing Working 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 Adelaide SA 5001

APPLICANT DETAILS

Family Name*

First Given Name*

Other Family Name

Other Given Name(s)

Specify Other Name Type Note: if you have more than one previous name,

list on a separate sheet and attach to application

Other Given Name(s)First Given Name

Current Residential Address*

Suburb/Town State Postcode

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)

/ /

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 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. 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 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 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 Category A required)

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: 21/11/2014 Page 2 of 2

CATEGORY A

CATEGORY B

POINT

VALUE

POINT

VALUE

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 Documents Land 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')