Fillable Printable National Police Checking Service Application / Consent Form

National Police Checking Service Application / Consent Form

For Office Use Only

Date Entered:

Name Auth Personnel Entered:

Result Date Dispatched:

Name & Signature of QA Approval/Manager (if required)

Payment Date & Payment Method

Payment Receipt attached

(Y/N)

Result Dispatch Method:

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NATIONAL POLICE CHECKING SERVICE APPLICATION FORM

(INDIVIDUALS - HEALTHCARE AND/OR VULNERABLE GROUPS)

PERSONAL INFORMATION

NAMES BY WHICH I AM, OR EVER HAVE BEEN, KNOWN

(including changes by Deed Poll)

1.________________________________ ______________________________________

Surname (current) Given Names (current)

2.________________________________ ______________________________________

Surname Given Names

SEX: M F DATE OF BIRTH: ______ / _______/ _______

(Please Circle) Day Month Year

PLACE OF BIRTH: _________________________________________________________

Suburb/Town State/Territory Country

PHONE NUMBER: ______________________ MOBILE: __________________________

PASSPORT: ______________________________________________________________

Type (Private, Govt or UN Refugee) Number Passport Country

DRIVER’S LICENCE NUMBER: _______________ STATE ISSUED BY: _____________________

FIREARMS LICENCE NUMBER: ______________ STATE/TERRITORY: _____________

Permanent Residential Address over Last Five Years

If full details of previous addresses are unavailable details of

town(s) and state(s) will suffice. Attach list if insufficient room.

If actual dates are unavailable, Details of year of

residence will suffice

Current

No/Street Suburb/Town State/Territory Postcode

Period of residence

/ / to / /

No/Street Suburb/Town State/Territory Postcode

/ / to / /

No/Street Suburb/Town State/Territory Postcode

/ / to / /

No/Street Suburb/Town State/Territory Postcode

/ / to / /

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NATIONAL CRIMINAL HISTORY CHECK

CONSENT TO OBTAIN PERSONAL INFORMATION

(INDIVIDUALS - PARTIAL EXCLUSION)

(BLOCK LETTERS and in BLACK INK)

I, ___________________________________________________________________________ hereby:

Family Name (Current) Given Names (Current)

1. acknowledge that I have read the Spent Convictions Schemes section of the Information sheet and understand that

Spent Convictions legislation (however described) in the Commonwealth and many States and Territories protects

“spent convictions” from disclosure;

2. understand that the national criminal history check for which I am applying is in a category for which a PARTIAL

exclusion has been granted from the application of the Spent Convictions legislation and that “spent” convictions and

findings of guilt relating to me of a type listed below will be released;

Serious offences, sexual offences, offences against the person, for which an exclusion has been granted in

respect to my application for employment/engagement in positions/occupations involving the care, instruction

or supervision of vulnerable persons (including children, aged persons, and the disabled).

3. have fully completed this Form, and the personal information I have provided in it relates to me, contains my full name

and all names previously used by me, and is correct;

4. acknowledge that the provision of false or misleading information is a serious offence;

5. acknowledge that I am providing information to the CrimTrac Agency (an Agency of the Commonwealth of Australia)

and the Australian police services by consenting to National Crime Check providing personal information about me

from this Form;

6. consent to:

(i) the CrimTrac Agency disclosing personal information about me to the Australian police services;

(ii) the Australian police services disclosing to the CrimTrac Agency, from their records, details of convictions and

outstanding charges, including findings of guilt or the acceptance of a plea of guilty by a court, that can be

disclosed in accordance with the laws of the Commonwealth, States and Territories and, in the absence of any

laws governing the disclosure of this information, disclosing in accordance with the policies of the police service

concerned; and

(iii) the CrimTrac Agency providing the information disclosed by the Australian police services to National Crime

Check in accordance with the laws of the Commonwealth; and

7. acknowledge that any information provided by me on this Form, or by the Australian police services, relates

specifically to

<specify position/occupation>_______________________________________________________________

Signature________________________________________ Date ____/____/_____

Note: The information you provide on this Form, and which the CrimTrac Agency provides to National Crime

Check on receipt of the Form, will be used only for the purpose stated above unless statutory obligations

require otherwise.

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NATIONAL POLICE CHECKING SERVICE

GENERAL INFORMATION

This Form is used by Health Outcomes International Pty Ltd (T/a “National Crime Check”) so as to obtain a national

criminal history check with your consent and at your request for Employment Screening.

Unless statutory obligations require otherwise, the information provided on this Form will not be used without your prior

consent for any purpose other than the purpose for which it has been requested.

NATIONAL CRIMINAL HISTORY CHECK

Information extracted from this Form will be forwarded to the CrimTrac Agency and other Australian police services

for

checking action. By signing the Form you are providing your consent to these agencies:

a) disclosing criminal history information that pertains to you from their own records to National Crime Check; and/or

b) accessing their records to obtain criminal history information that in turn will be disclosed to National Crime Check.

Such criminal history information may include outstanding charges, and criminal convictions/findings of guilt recorded

against you that may be disclosed according to the laws of the relevant jurisdiction and, in the absence of any laws

governing the release of that information, according to the relevant jurisdiction's information release policy.

It is usual practice for an applicant’s personal information to be disclosed to Australian police services for them to use for

their respective law enforcement purposes including the investigation of any outstanding criminal offences.

SPENT CONVICTIONS SCHEMES

Child-related employment screening has been conducted around Australia for many years in an attempt to minimise the

risk of harm to children from persons responsible for their care and supervision. A key component of this is the provision of

criminal history information (including “spent” convictions and findings of guilt of prescribed/specified offences) to

employers and authorised screening organisations. In certain states child-related employment screening processes are

governed by legislation.

South Australia

South Australia does not have Spent Convictions legislation, but South Australia Police (SAPOL) has developed a policy

based on the Spent Convictions provisions of the Crimes Act 1914 (Cth) and the State’s Information Privacy Principles.

A conviction will be regarded as being “spent” or “inactive” and will not be released if:

 at the time of the offence being committed, the person was an adult (18 years or over) and 10 years have elapsed

since the conviction of the offence, and no further convictions have been incurred; OR

 in the case of a person who was a child (under 18 years) at the time the offence was committed and 5 years have

elapsed since the conviction of the offence, and no further convictions have been incurred; OR

 in the case of a conviction that has been quashed or set aside, a pardon was issued in respect to that conviction. The

conviction will be disregarded from the date that it is quashed, set aside or a pardon issued.

If an individual re-offends within the above waiting period, all prior findings of guilt are released including juvenile

convictions. Convictions recorded in other jurisdictions may be used to reactivate South Australian convictions.

Australian Federal Police, New South Wales Police Force, Victoria Police, Queensland Police Service, South Australia Police, Western Australia

Police, Tasmania Police, Northern Territory Police Force.

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Convictions from other jurisdictions will be released in accordance with that jurisdiction’s spent conviction/rehabilitation

legislation/policies.

A serious conviction can never be regarded as “spent” or “inactive” and will always remain on an offender’s criminal

history unless quashed or pardoned. A serious offence is one where the sentence imposed was a fine, bond, community

service order or imprisonment for a period of not less than 30 months. Serious offences that cannot become “spent” or

“inactive” only activate findings of guilt for the usual waiting period.

“Spent” or “inactive” convictions are not released unless required by an Act, Registration Board, requested for court

purposes, or the individual has largely unsupervised contact with vulnerable groups. Traffic offences under the Road

Traffic Act are not considered for release unless they result in a prison sentence or suspended sentence.

SAPOL will release all “proven” court outcomes (“active” convictions, findings of guilt) and charges that have not been

heard or finalised by a Court (pending matters are released with a warning stressing that they must not be regarded as

“proven”.) SAPOL will also release ”inactive” and “not proven” court outcomes if the individual is employed or is being

considered for employment/placement with vulnerable groups.

Relevant offences may include offences against the person, drug offences and some firearm offences. Relevant offences

with an unproven result by reason of insanity or mental impairment may be considered for release in the interest of public

safety.

Other Australian police services

Where a criminal history record with another Australian police service has been obtained, any jurisdictional legislation

(and/or release policy) affecting the disclosure of those records will be applied before that record is released. Under

various pieces of Commonwealth, State and Territory legislation a person has the right, in particular circumstances or for

a particular purpose, to not disclose certain convictions/findings of guilt. Such convictions (widely referred to as “spent” or

“rehabilitated” convictions) will not be released unless there is an applicable exemption or exclusion from such legislation

and/or release policy. Please contact individual police services directly for further information about their release policies

and any legislation that affects them.

PROVISION OF FALSE OR MISLEADING INFORMATION

You are asked to certify that the personal information you have provided on this form is correct. If it is subsequently

discovered, for example as a result of a check of police records, that you have provided false or misleading information,

you may be assessed as unsuitable.

It is a serious offence to provide false or misleading information.

You should note that the existence of a record does not mean that you will be assessed automatically as being unsuitable.

Each case will be assessed on its merit, so it is in your interest to provide full and frank details in the form.

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NATIONAL CRIMINAL HISTORY CHECK

PROOF OF IDENTITY CHECKLIST

The Applicant needs to furnish original documents or certified true copes and/or types of identification that are equal to

(or greater) than 100 points.