Fillable Printable National Police Check (NPC) Application Form - Australia

National Police Check (NPC) Application Form - Australia

Payment

Mandatory Details

Fingerprints (attached)

Consent

Proof of IDs

Fingerprints (paid)

Notes:

Ref No:

Note: If you need to record additional names please use Attachment B.

Page 1 of 4

NATIONAL POLICE CHECK (NPC)

APPLICATION FORM

Website: www.afp.gov.au

Email: [email protected]

ABN: 17 864 931 143

Office Hours: 8am to 5pm, Monday to Friday (except A.C.T Public Holidays)

Please complete this form by referring to the Application Completion Guide. If completing manually, use BLOCK LETTERS and black ink. Mark check boxes with a cross (X).

SECTION 1: Type of check required

(this section must be completed - select only one)

Name Check Only (Fee: $42) Name and Fingerprint Check (Fee: $99 if fingerprints are taken and paid, $139 if not paid)

SECTION 2: Fingerprints (Optional) (complete only where fingerprints are required and/or authorised by law)

Ink Livescan

Fingerprint Type: (select only one)

Police Station: Officer’s Name & No:

Date Taken:

(DD MM YYYY)

AFP NPC FORM-5021

Please note that a fingerprint check is only required under very limited circumstances. Please ensure that you are actually required to have a fingerprint check conducted

before going to the expense of this level of check by checking with the organisation/department requesting the check.

Note: Fingerprints can be taken by your local police jurisdiction or the AFP. Where fingerprints are taken by the AFP and the AFP charges for this service a receipt must be

obtained and supplied to Criminal Records with this application.

Ref No:

SECTION 4: Other names you have used (including former, maiden name/s etc)

Family Name / Surname :

First Name / Given Name:

Other Given Names:

Former Name Also known as

Family Name / Surname :

First Name / Given Name:

Other Given Names:

Former Name Also known as

SECTION 3: Details of Applicant

(this section must be completed)

Family Name / Surname :

First Name / Given Name:

Other Given Names:

Were you born in Australia?

Yes

Suburb / Town of Birth:

Country of Birth:

State:

Daytime Contact Number:

Email Address

(optional):

Australian Driver’s Licence No:

Issuing State:

Date of Birth:

Male Female

(DD MM YYYY)

Date of Birth:

(DD MM YYYY)

Date of Birth:

(DD MM YYYY)

Telephone: 02 6102 6102 Fax: 1300 549 456

Page 2 of 4

SECTION 5: Current & Previous Residential Addresses

(this section must be completed)

Previous Residential Address (must not be a PO Box or Business Address) - Note: To record additional addresses please use Attachment C.

Unit No / Street No /

Street Name:

Suburb / Town / Locality:

Country:

Postcode: State:

Current Residential Address (must not be a PO Box or Business Address)

Unit No / Street No /

Street Name:

Suburb / Town / Locality:

Country:

Postcode: State:

Date you started living at this address: (DD MM YYYY)

(DD MM YYYY)

Date you started living at this address:

AFP NPC FORM-5022

This can be a PO Box or Business Address. Note: If not completed, the certificate will be sent to the applicant at the Current Residential Address specified

in Section 5.

(optional) I authorise the Police Certificate to be forwarded to the following person/organisation

SECTION 6: Mailing Address for Police Certificate

Unit No / Street No /

Street Name:

Suburb / Town / Locality:

Country:

State:Postcode:

(this section must be completed)

Cardholder’s Name:

Credit Card Number:

Bank Cheque

Money Order

I authorise the AFP or their agent to process the relevant

application amount from the above credit card account.

NB: The amount to be deducted is as per the selected

fee specified on Page 1 (Section 1) of this form,

plus a surcharge where payment is by Credit Card.

FOR OFFICE USE ONLY

Payment Confirmation No:

Processed Amount: (AUD)

SECTION 7: Payment Details

Expiry Date: (MM YY)

Attn. To / Organisation:

Mastercard Visa Amex

CVC Number:

0.528% 0.528% 1.595%)(Surcharge:

Card Declined

Credit Card/Debit Card (please complete card details below)

Previous Residential Address (must not be a PO Box or Business Address) - Note: To record additional addresses please use Attachment C.

In the event you have not resided in your current location for 10 years or greater, please provide details of your previous residential addresses.

Page 3 of 4

SECTION 8: Purpose of Check

(Choose one purpose only from the following list)

If the purpose for your NPC is not listed or you are unsure please call the National Police Check Help Desk on 02 6102 6102 between 8am and 5pm (Australian EST).

Offences recorded in the Commonwealth that will be released

(Part VIIC Crimes Act 1914)

Commonwealth Purpose / EmploymentCode Number

(Spent Convictions Act 2000)

Offences recorded in the A.C.T. that will be released

A.C.T. Purpose / Employment

AFP NPC FORM-5023

Disabled Care provider/worker or Hospital Employment

Child Care provider/worker

Brothel or Escort Agency Owner/Operator/Interested party

Aged Care provider/worker

CASA ASSC

Care, instruction or supervision of children

Care of intellectually disabled persons

AUSTRAC employee/consultant

Australian Securities and Investments Commission (ASIC) Consumer Credit/Financial

Services Licensing Requirements

Australian Securities and Investments Commission (ASIC) employee/consultant

Aged Care Key Personnel

Aged Care staff/volunteers

Unspent offences (a) a sexual offence; or (b) any other offence against

the person if the victim of the offence was under 18 at the time the

offence was committed

Unspent offences and offences against the person

SECTION 9: Applicant’s Consent

(this section must be completed)

ii.

iii.

iv.

vi.

vii.

I acknowledge I have read all the instructions while completing this form and I am aware exclusions from spent convictions legislation may apply to some categories of NPCs.

The personal information I have provided on this form (including fingerprints if supplied) and all the attachments (if any) relate to me and are correct.

I acknowledge the details contained on this form, including fingerprints where relevant, will be forwarded to the AFP, CrimTrac, and/or the Police Services of the States or Territories of the Commonwealth of Australia.

I consent to the AFP and any other Australian police force extracting details of any convictions, findings of guilt or pending court proceedings relating to me, including in relation to any traffic offence, and providing that information

to me or to the Employer/Organisation named in Section 6.

I acknowledge the information provided on this form will not be used without my prior consent for any other purpose, unless otherwise authorised by law.

I acknowledge that any information provided on this form or disclosed by the police as a result of the records check may be taken into account by any organisation to whom I present the results of the records check in assessing

my suitability to receive the entitlement.

I acknowledge that only details contained in this application or on attachments signed by me will be checked and that should I subsequently require further names and/or details to be checked then I will be required to submit

a new application and payment.

Parent/Guardian’s Name:

Parent/Guardian’s

Signature:

Date:

Applicant’s Signature: Date:

If you are under 18 years of age (as at the date of the application), please provide consent below from a parent/guardian.

viii.

I understand that it is an offence to provide false or misleading information in this application, or omit to provide information that may result in this application being false or misleading.

Commonwealth department employee

Pre employment/standard disclosure

Teacher/teacher’s aide

Working in a School

Child/Aged/Disabled Care provider/worker

Judge/Magistrate/Justice of the Peace/ Police Officer/Prison Officer

Interactive Gambling Licence/Casino Employee

Firearms Licence/permit

Fire fighting/prevention

Care, instruction or supervision of children/ Care of intellectually disabled persons/

Aged Care staff/volunteers

Superannuation Trustee/Custodian/Investment manager or Responsible officer of a

body corporate that is a trustee, investment manager or custodian of a superannuation

entity

Overseas employment/visa

Immigration/Citizenship ** Please note, fingerprints are not required unless specifically

advised by the Department of Immigration and Citizenship

Immigration Detention Centre Employment

Employee with access to secret or top secret information

Unspent offences, offences against the person and (i) a sexual offence;

or (ii) any other offence against the person if the victim of the offence

was under 18 at the time the offence was committed

All offences

Unspent offences and Arson or Attempted Arson offences

Unspent offences

All offences

Unspent offences and offences against the person

Unspent offences

All offences

Unspent offences

All offences

Unspent offences and offences involving violence

All offences

Unspent offences

Unspent offences and offences in respect of dishonest conduct

Unspent offences

Code Number

Page 4 of 4

Attachment A: Proof of Identity

(this section must be completed)

A minimum of 100 points of identification has to be provided with the application. Please ensure that only photocopies of the original documents are attached.

Required on document

N = Name, P = photo

A = Address, S = Signature

You must supply at least ONE Primary document

Foreign documents must be accompanied by an official translation

Points

Worth

Points gained

(applicant to fill)

Tick if

included

Prior to submitting your application, please complete the checklist below to ensure your request can be processed in a timely manner. Failure to complete or supply any

part of the application may result in it being returned prior to processing.

All required details in Sections 1 to 9 are complete.

I can be reached during business hours on the phone number I have provided in section 3.

I have attached photocopies of my identification, for documents selected in attachment A above.

I have provided my credit card details for electronic payment or I will attach a cheque or money order payable to the AFP for the current fee.

(optional) If a fingerprint check is required, I have provided my fingerprints and if relevant, a copy of the receipt for payment.

Alternatively you can scan and email all the documents to: [email protected]

Once all the above steps have been completed, attach your photocopied identification documents and payment to the application form and post to:

Australian Federal Police

Criminal Records

Locked Bag 8550

CANBERRA CITY ACT 2601

Submission Checklist

AFP NPC FORM-5024

Certificate of Identity issued by the Australian Government to refugees and non Australian citizens for

entry to Australia

Photo identification card issued for Australian regulatory purposes (e.g. Aviation/Maritime Security

identification, security industry etc.)

Documents issued outside Australia (equivalent to Australian documents). Must have official

translation attached

Foreign Passport (current)

Australian Passport (current or expired last 2 years but not cancelled)

Australian Citizenship Certificate

Full Birth certificate (not extract)

Australian Driver License/Learner’s Permit

Current (Australian) Tertiary Student Identification Card

Government employee ID (Australian Federal/State/Territory)

Defense Force Identity Card (w/ photo or signature)

Department of Veterans Affairs (DVA) card

Centrelink card (with reference number)

Birth Certificate Extract

Birth card (NSW BDM only)

Medicare card

Credit card or account card

Australian Marriage certificate (Registry issue only)

Decree Nisi / Decree Absolute (Registry issue only)

Change of name certificate (Registry issue only)

Bank statement

Property lease agreement - current address

Taxation assessment notice

Australian Mortgage Documents

Rating Authority - eg Land Rates

Utility Bill - electricity, gas, telephone (less than 12 months old)

Reference from Indigenous Organisation

Attachment B: Other names you have used

(use only if required)

Family Name / Surname :

First Name / Given Name:

Other Given Names:

Former Name Also known as

Family Name / Surname :

First Name / Given Name:

Other Given Names:

Former Name Also known as

Family Name / Surname :

First Name / Given Name:

Other Given Names:

Former Name

Also known as

Attachment C: Previous Residential Address

Unit No / Street No /

Street Name:

Suburb / Town / Locality:

Country:

Postcode: State:

Unit No / Street No /

Street Name:

Suburb / Town / Locality:

Country:

Postcode: State:

Unit No / Street No /

Street Name:

Suburb / Town / Locality:

Country:

Postcode: State:

Optional Attachment

(use only if required - must not be a PO Box or Business Address)

Date of Birth:

(DD MM YYYY)

Date of Birth:

(DD MM YYYY)

Date of Birth:

(DD MM YYYY)

AFP NPC FORM-5025

Date you started living at this address: (DD MM YYYY)