Fillable Printable Police Check Application Form - Western Australia
Fillable Printable Police Check Application Form - Western Australia
Police Check Application Form - Western Australia
NATIONAL POLICE CHECKING SERVICE (NPCS)
APPLICATION/CONSENT FORM
(ACCREDITED AGENCIES - CUSTOMERS)
Page 1
Generic Application Form (Agency) v1.3
Please select appropriate box only:
Employee
Contractor/Consultant
Volunteer
Other (Please specify)
Is this a renewal check?
Yes
No
SECTION 1: PERSONAL INFORMATION - Use BLOCK LETTERS and black ink to complete this form. Mark check boxes with an (X)
Names by which I am, or ever have been, known including Alias (A), name change by Marriage (M) or previous name, change by
Deed Poll (P) If more room is required, list on separate sheet, sign and send the sheet with this application form. Additional sheet included?
Yes
No
Surname
(Primary)
Given Names
(Primary)
Surname
A
P
M
Given Names
Surname
A
P
M
Given Names
Gender
Male
Female
Unknown/
Other
Date of Birth
(dd/mm/yyyy)
Place of Birth
Suburb/Town
Country
State/Territory
Contact Details
Phone
Home
Work
Mobile
Email
Other Details
Australian Driver's Licence No
Issued By
Firearms Licence No
State/Territory
Passport No
Passport Country
Passport Type
Government
UN Refugee
Private
Permanent Residential Address Over Last Five Years
If more room is required, list on separate sheet, sign and send the sheet with this application form. Additional sheet included?
Yes
No
If full details of previous addresses are unavailable, details of town(s) and state(s)/
territory(ies) of residence will suffice.
If actual dates are unavailable, details of
year of residence will suffice
Current
No/Street
Suburb
State/
Territory
P'code
Period of residence
to
Country
Previous (if applicable)
No/Street
Suburb
State/
Territory
P'code
to
Country
Previous (if applicable)
No/Street
Suburb
State/
Territory
P'code
to
Country
NATIONAL POLICE CHECKING SERVICE (NPCS)
APPLICATION/CONSENT FORM
(ACCREDITED AGENCIES - CUSTOMERS)
Page 2
Generic Application Form (Agency) v1.3
SECTION 2: PROOF OF IDENTITY (100-POINT CHECK)
Important: Should the Accredited Agency apply a more rigorous proof of identity check by choosing to exceed the 100
points requirement, please refer to your information pack/instructions before continuing.
When applying for a national police history check you must provide proof of your identity with your application. You will be asked
to provide personal identity documents that add up to a minimum of 100 points. The combination of documents supplied should,
as a minimum, evidence your full name and date of birth. All documents must be originals or certified true copies. A certified copy
means a document that has been certified as a true copy of an original by a person listed in Schedule 2 of the Statutory Declarations
Regulations 1993 (Cth) and is available from
http://www.comlaw.gov.au by searching for "Statutory Declarations Regulations 1993".
Documents must be selected from the list below.
Change of Name
If the name you use to apply for a national police history check is different from that shown on any of your personal identity
documents, you must provide evidence of the name change, e.g. Marriage or Change of Name Certificate issued by a State or
Territory Registry of Births, Deaths and Marriages and Divorce papers issued by the Family Court. These documents must be
originals or certified true copies and DO NOT count towards the 100-points. If you use a change of name document you must
provide in Section 1 the other names you have used.
Document Type
Document
100 points must include ONE Primary Document, or at least ONE Secondary
Document which must contain a photograph
Points Value
Points Scored
Only one form of identification
accepted from this category
PRIMARY
•
•
•
•
•
Birth Certificate/Birth Extract
Australian Passport (Current, or expired within the
previous two years, but not cancelled)
Australian Citizenship Certificate
International Passport (Current, or expired within the
previous two years, but not cancelled)
Other document of identity having same characteristics as
a passport e.g. diplomatic/refugee (Photo or Signature)
70
Your initial Secondary Documents
will score 40 points, any
additional documents will be
awarded 25 points each
SECONDARY
•
•
•
•
•
•
•
•
Current Licence or Permit (Government Issued)
Working With Children/Teachers Registration Card
ASIC/MSIC Card
Public Employee Photo ID Card (Government Issued)
Department of Veterans' Affairs Card
Centrelink Pensioner Concession Card or Health Care Card
Current Tertiary Education Institution Photo ID
Reference from a Doctor (must have known the applicant
for a period of at least 12 months)
40 or 25
•
•
•
•
•
•
•
•
•
•
•
•
Foreign/International Driver’s Licence
Proof of Age Card (Government Issued)
Medicare Card/Private Health Care Card
Council Rates Notice
Property Lease/Rental Agreement
Property Insurance Papers
Tax Declaration
Superannuation Statement
Seniors Card
Electoral Roll Registration
Motor Vehicle Registration or Insurance Documents
Professional or Trade Association Card
25
If you wish to use more than one
of these documents they must be
from different organisations
•
•
•
Utility Bills (e.g. Telephone, Gas, Electricity, Water)
Credit/Debit Card
Bank Statement/Passbook
25
NATIONAL POLICE CHECKING SERVICE (NPCS)
APPLICATION/CONSENT FORM
(ACCREDITED AGENCIES - CUSTOMERS)
Page 3
Generic Application Form (Agency) v1.3
SPECIAL PROVISIONS ONLY TO BE USED IF 100 POINT CHECK ABOVE CANNOT BE MET
The full 100 point check is required
when the applicant has been in
Australia for longer than 6 weeks
For recent arrivals in Australia (6 weeks or less – proof of
arrival date required) current passport
100
Aboriginal person or Torres Strait
Islander resident in a remote area/
community
Identity of applicant ordinarily resident in an isolated area
verified by TWO persons recognised as ‘Community
Leaders’ of the community to which the applicant belongs
100
Child Under 18
•
•
•
•
•
Birth Certificate/Birth Extract
Australian Passport (current, or expired within the
previous two years, but not cancelled)
Australian Citizenship Certificate
International Passport (current, or expired within the
previous two years, but not cancelled)
Other document of identity having same characteristics
as a passport eg. diplomatic/refugee (Photo or
Signature)
Or
Statement from an educational institution, signed by the
principal or deputy principal, confirming that the child
attends the institution (statement must be on the
institution’s letterhead)
100
TOTAL POINTS
Points must equal or exceed a total of 100
Total Points
Scored:
VERIFICATION - (OFFICE USE ONLY)
NOTE: To be completed by the Accredited Agency or its Customer (as defined in the CrimTrac agreement).
I declare that I have sighted and confirmed the applicant’s original or certified true copy personal identity documents and that verification has been achieved using
the 100 point check. I am satisfied as to the correctness of the applicant’s identity.
Signature of authorised checking officer:
Date:
Printed name of authorised checking officer:
SECTION 3: ACCREDITED AGENCY DETAILS
Accredited Agency
(Legal Name)
THE STATE OF WESTERN AUSTRALIA (DEPARTMENT OF EDUCATION SERVICES)
ABN
86 936 328 729
SECTION 4: AUTHORISATION TO DISCLOSE PERSONAL INFORMATION
Is the result of the national police history check to be forwarded/disclosed only to the accredited agency named in Section 3 above?
If No: I authorise the result of the national police history check to be forwarded/disclosed to the following employer/organisation to assess my suitability:
Yes
No
Employer/Organisation
(Legal Name)
ABN
SECTION 5: PURPOSE OF THE NATIONAL POLICE HISTORY CHECK
Provide details of relevant position/entitlement, place of work and whether you have contact with vulnerable groups. e.g. Client Services Officer in a call centre,
Janitor at a school, Nurse in an aged care facility with direct care of disabled & aged persons or Flight Attendant with direct care of children).
Position/Occupation or
Entitlement
NATIONAL POLICE CHECKING SERVICE (NPCS)
APPLICATION/CONSENT FORM
(ACCREDITED AGENCIES - CUSTOMERS)
Page 4
Generic Application Form (Agency) v1.3
SECTION 6: GENERAL INFORMATION
GENERAL INFORMATION
This Form is used as part of the assessment process to determine whether a
person is suitable for employment or other engagement for work or other
entitlements.
Unless statutory obligations require otherwise, the information provided on
this Form will not be used without your prior consent for any purpose other
than in relation to the assessment of your suitability. You may be required to
complete another consent form in the future in relation to employment in
other positions.
NATIONAL POLICE HISTORY CHECK
A national police history check is an integral part of the assessment of your
suitability.
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.
Information extracted from this Form will be forwarded to the CrimTrac
Agency and other Australian police agencies
1
for checking action. By signing
this Form you are consenting to these agencies accessing their records to
obtain and disclose police history information that relates to you to:
a)
b)
the Accredited Agency named in Section 3 above; and
where applicable the employer/organisation named in Section 4 above.
Police 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.
SPENT CONVICTIONS SCHEMES
The following information is provided as general guidance and is not
exhaustive.
The aim of Spent Convictions legislation
2
is to prevent discrimination on the
basis of certain previous convictions. Spent convictions legislation limits the
use and disclosure of older, less serious convictions and findings of guilt.
Spent convictions of specific offences will be released where the check is
required for certain purposes regardless of how old the convictions are.
Each Australian police agency will apply the relevant Spent Convictions
legislation/information release policy prior to disclosure.
If further information or clarification is required please contact the individual
police agencies directly for further information about their release policies
and any legislation that affects them.
Commonwealth
Part VIIC of the Crimes Act 1914 (Cth) deals with aspects of the collection, use
and disclosure of old conviction information. The main element of this law is
a “Spent Convictions Scheme”. The aim of the Scheme is to prevent
discrimination on the basis of certain previous convictions, once a waiting
period (usually 10 years) has passed and provided the individual has not re-
offended during this period. The Scheme also covers situations where an
individual has had a conviction “quashed” or has been “pardoned”.
A “spent conviction” is a conviction of a Commonwealth, Territory, State or
foreign offence that satisfies all of the following conditions:
•
•
•
•
it is 10 years since the date of the conviction (or 5 years for juvenile
offenders); AND
the individual was not sentenced to imprisonment or was not sentenced
to imprisonment for more than 30 months; AND
the individual has not re-offended during the 10 years (5 years for juvenile
offenders) waiting period; AND
a statutory or prescribed exclusion does not apply. (A full list of exclusions
is available from the Office of the Australian Information Commissioner).
1
Australian Federal Police, The New South Wales Police Force, Victoria Police,
Queensland Police Service, South Australia Police, Western Australia Police,
Tasmania Police Service, Northern Territory Police Force.
2
Applicable Spent Convictions legislation, as amended from time to time.
The law affects Commonwealth authorities in the following ways:
•
•
a person with a conviction protected by Part VIIC does not have to disclose
that conviction to any person, including a Commonwealth authority,
unless an exclusion applies;
Commonwealth authorities are prohibited from accessing, disclosing or
taking into account spent convictions of Commonwealth offences.
Part VIIC and Crimes Regulations 1990 (Cth) provide for “statutory” or
“regulatory” exclusions that will prevent certain Commonwealth convictions
from being spent in certain circumstances.
New South Wales
In New South Wales the Criminal Records Act 1991 (NSW) governs the effect of a
person’s conviction for a relatively minor offence if the person completes a
period of crime-free behaviour, and makes provision with respect to quashed
convictions and pardons.
A “quashed” conviction is a conviction that has been set aside by the Court. A
“pardon” means a free and absolute pardon that has been granted to a person
because he/she was wrongly convicted of a Commonwealth, Territory, State or
foreign offence.
In relation to NSW convictions, a conviction generally becomes a “spent
conviction” if a person has had a 10-year crime-free period from the date of the
conviction. However, certain convictions may not become spent. These include:
•
•
•
•
where a prison sentence of more than 6 months has been imposed
(periodic or home detention is not considered a prison sentence);
convictions against companies and other corporate bodies;
sexual offences pursuant to the Criminal Records Act 1991; and
convictions prescribed by the Regulations.
Queensland
Under the Criminal Law (Rehabilitation of Offenders) Act 1986 (Qld) a conviction
automatically becomes spent upon completion of the prescribed
(rehabilitation) period. This period is:
•
•
10 years for convictions of indictable offences where the offender was an
adult at the time of conviction; and
5 years for other convictions (summary offences or where the offender
was a juvenile).
Where a person is convicted of a subsequent offence (an offence other than a
simple or regulatory offence) during the rehabilitation period, the period runs
from the date of the subsequent conviction.
Convictions where the offender is sentenced to more than 30 months
imprisonment (whether or not that sentence is suspended) are excluded from
the regime.
Once the rehabilitation period has expired, it is lawful for a person to deny
(including under oath) that the person has been convicted of the offence, and
the conviction must be disregarded for occupational licensing purposes (subject
to certain exceptions, see below). It is unlawful for any person to disclose the
conviction unless:
•
•
•
the convicted person consents;
the Minister has granted a permit authorising disclosure (where there is a
legitimate and sufficient purpose for disclosing);
the disclosure is subject to an exemption.
South Australia
Release of information on a National Police Check is governed by the Spent
Convictions Act 2009 (SA). It is an offence to release information regarding the
convictions of a person if those convictions are deemed to be ‘spent’ under the
Act.
A spent conviction is one that cannot be disclosed or taken into consideration
for any purpose. Eligible convictions become spent following a 10-year
conviction and proven offence-free period for adults, and a 5-year conviction
and proven offence-free period for juveniles.
The Act defines a conviction as:
•
•
a formal finding of guilt by a Court;
a finding by a Court that an offence has been proved.
Certain convictions can never be spent. These include but are not limited to:
•
•
convictions of sex offences;
convictions where a sentence is imposed of more than 12 months
imprisonment for an adult, or 24 months imprisonment for a juvenile.
NATIONAL POLICE CHECKING SERVICE (NPCS)
APPLICATION/CONSENT FORM
(ACCREDITED AGENCIES - CUSTOMERS)
Page 5
Generic Application Form (Agency) v1.3
SECTION 6: GENERAL INFORMATION (cont)
South Australia (cont.)
Schedule 1 of the Act sets out a number of exceptions to the rule where spent
convictions can be released. Some examples of this include:
•
•
•
the care of children;
the care of vulnerable people (including the aged and persons with a
disability, illness or impairment);
activities associated with statutory character tests for licensing.
Interstate offences are released in accordance with that State or Territory's
spent conviction / rehabilitation legislation and policy. Intelligence-type
information is not released.
Victoria Police
For the purposes of employment, voluntary work or occupational licensing/
registration, police may restrict the release of a person’s police record
according to the Victoria Police “Information Release Policy”. If you have a
police record the “Information Release Policy” may take into account the age
of the police record and the purpose for which the information is being
released. If 10 years have elapsed since you were last found guilty of an
offence, police will, in most instances, advise that you have no disclosable
court outcomes. However, a record over 10 years may be released if:
•
•
•
it includes a term of imprisonment longer than 30 months;
it includes a serious, violent or sexual offence and the check is for the
purpose of working with children, elderly people or disabled people;
it is in the interests of crime prevention or public safety.
Findings of guilt without conviction and good behaviour bonds may be
released. Recent charges or outstanding matters under investigation that
have not yet gone to court may also be released.
Western Australia
Under Section 7(1) of the Spent Convictions Act 1988 (WA) only “lesser
convictions” can be spent by Western Australia Police, after a time period of
10 years plus any term of imprisonment that may have been imposed. A
lesser conviction is one for which imprisonment of 12 months or less, or a fine
of less than $15,000 was imposed.
All other convictions, such as “serious convictions” applicable under Section 6
of the Act can only be spent by applying to the District Court. At the time of
sentencing, the Court may make a “spent conviction order” under the
Sentencing Act 1995 (WA) that the conviction is a spent conviction for the
purposes of the Spent Convictions Act 1988 (WA).
Northern Territory
Under the Criminal Records (Spent Convictions) Act 1992 (NT), a conviction
becomes spent automatically (in the case of an adult or juvenile offender
convicted in a Juvenile Court) and by application to the Police Commissioner
(in the case of a juvenile convicted in an adult court) upon completion of the
prescribed period. The prescribed period is:
•
•
10 years for offences committed while an adult; and
5 years for offences committed as a juvenile
The period starts on completion of any sentence of imprisonment. A
subsequent traffic conviction is only taken into account for prior traffic
offences (except more serious traffic offences which cause injury or death).
Once a conviction becomes spent:
•
•
•
•
a person is not required to disclose the existence of the conviction;
questions relating to convictions and a person’s criminal record will be
taken only to apply to unspent convictions;
it is unlawful for another person to disclose the existence of a spent
conviction except as authorised by the Act;
spent convictions are not to be taken account in making decisions about
the convicted person’s character or fitness.
Australian Capital Territory
Generally, under the Spent Convictions Act 2000 (ACT), a conviction becomes
spent automatically at the completion of the prescribed (crime-free) period.
This period is:
•
•
10 years for convictions recorded as an adult; or
5 years for convictions recorded as a juvenile.
The period begins to run from the date a sentence of imprisonment is
completed, or, where no sentence of imprisonment is imposed, from the date of
conviction. A person must not be subject to a control order or convicted of an
offence punishable by imprisonment during this period. If a person is convicted
of an offence, which was committed in the crime-free period, but the conviction
is not incurred until after the crime-free period, the spent conviction may be
revived and will not become spent again until the offender has achieved the
relevant crime-free period in respect of the later offence.
The effect of conviction becoming spent is that:
•
•
•
•
•
the convicted person is not required to disclose any information
concerning the spent conviction;
any question concerning criminal history is taken only to apply to unspent
convictions;
references in Acts or statutory instruments to convictions or character or
fitness does not include spent convictions, and it is an offence to disclose
information regarding spent convictions;
it is unlawful for a person who has access to a person’s criminal record held
by a public authority to disclose a spent conviction;
it is unlawful for a person to fraudulently or dishonestly obtains
information about a spent conviction from records kept by a public
authority.
Tasmania
Under the Annulled Convictions Act 2003 (Tas) a conviction is annulled upon
completion of the prescribed period of good behaviour. This period is:
•
•
10 years where the offender was an adult at the time of conviction; or
5 years where the offender was a juvenile at the time of conviction.
A person is taken to be of good behaviour for the required period if, during that
period, he or she is not convicted of an offence punishable by a term of
imprisonment. If the person is so convicted, the qualifying period (for the
original offence) starts to run from the date of the subsequent conviction. A
subsequent traffic conviction is only taken into account for prior traffic offences
(except more serious traffic offences which cause injury or death).
Only “minor” convictions can become annulled. A minor conviction is a
conviction other than one for which a sentence of imprisonment of more than 6
months is imposed, a conviction for a sexual offence or a prescribed conviction.
A minor conviction is also annulled if the offence ceases to be an offence.
Once an offence is annulled the convicted person is not required to disclose any
information concerning the spent conviction. Any question concerning criminal
history is taken only to apply to unspent convictions, and references in Acts or
statutory instruments to convictions or character or fitness do not include spent
convictions. An annulled conviction or the non-disclosure of the annulled
conviction is not grounds for refusing the person any appointment, post, status
or privilege or revoking any appointment, post, status or privilege.
•
•
•
•
a person is not required to disclose the existence of the conviction;
questions relating to convictions and a person’s criminal record will be
taken only to apply to unspent convictions;
it is unlawful for another person to disclose the existence of a spent
conviction except as authorised by the Act;
spent convictions are not to be taken account in making decisions about
the convicted person’s character or fitness.
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.
NATIONAL POLICE CHECKING SERVICE (NPCS)
APPLICATION/CONSENT FORM
(ACCREDITED AGENCIES - CUSTOMERS)
Page 6
Generic Application Form (Agency) v1.3
SECTION 7: CONSENT TO OBTAIN PERSONAL INFORMATION
National Police History Check
(BLOCK LETTERS and in BLACK INK)
I,
Family Name (Primary)
Given Names (Primary)
hereby:
1.
2.
3.
4.
5.
6.
acknowledge that I have read the General Information sheet and understand that Spent Convictions legislation (however described) in the
Commonwealth and many States and Territories protects “spent convictions” from disclosure;
understand that the position/entitlement for which I am being considered may be in a category for which exclusions from Spent Convictions
legislation apply;
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;
acknowledge that the provision of false or misleading information is a serious offence;
acknowledge that the Accredited Agency named in Section 3 above is collecting information in this Form to provide to the CrimTrac Agency
(an Agency of the Commonwealth of Australia) and the Australian police agencies;
consent to:
(i)
(ii)
(iii)
(iv)
the CrimTrac Agency disclosing personal information about me to the Australian police agencies;
the Australian police agencies 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 agency concerned;
the CrimTrac Agency providing the information disclosed by the Australian police agencies to the Accredited Agency named in Section 3
above, in accordance with the laws of the Commonwealth; and
where applicable, the Accredited Agency named in Section 3 above disclosing to the employer/organisation named in Section 4 above
personal information about me to assess my suitability in relation to my employment/entitlement; and
7.
8.
9.
10.
acknowledge that any information provided by me on this Form relates specifically to the purpose identified in Section 5 above;
acknowledge that any information provided by the Australian police agencies or the CrimTrac Agency, relates specifically to the purpose
identified in Section 5 above;
acknowledge that personal information that I provide in this Form may be disclosed to the Accredited Agency named in Section 3 above
(including contractors or related bodies corporate) located in Australia or overseas for administrative purposes; and
acknowledge that it is usual practice for an applicant’s personal information to be disclosed to Australian police agencies for them to use for
their respective law enforcement purposes including the investigation of any outstanding criminal offences.
Note:
The information you provide on this Form, and which the CrimTrac Agency provides to the Accredited Agency named in Section
3 above, on receipt of the Form, will be used only for the purpose stated above unless statutory obligations require otherwise.
Applicant's Signature
Date
Parent/Guardian Consent - If you are under 18 years of age provide consent below from a parent /guardian.
Parent/Guardian
Signature
Date
Parent/Guardian name
printed in full
