Fillable Printable Voluntary Disclosure Form - Victoria Police
Fillable Printable Voluntary Disclosure Form - Victoria Police
Voluntary Disclosure Form - Victoria Police
SIGNED: ___________________________________ DATE: ___ / ___ / ___
VOLUNTARY DISCLOSURE FORM
INSTRUCTIONS:
Ensure to complete and sign ALL pages and post to:
Recruiting Services Branch
Victoria Police Centre
637 Flinders Street
Melbourne VIC 3005
A response will be emailed / posted to you in due course.
Note: Faxed and emailed forms will NOT be accepted and will be destroyed on arrival
.
*******YOU MUST INDICATE ONE OF THE FOLLOWING*******
Does your enquiry relate to an application for: PSO POLICE
PERSONAL DETAILS (Please type in the grey space provided)
Surname / Family Name:
Given Names:
Date of Birth:
Any previous Surname/s:
Previous Given Names / Alias:
Gender:
Male:
Female
Previous Enquiry or Application:
If YES – provide Ref #:
Home address:
Occupation:
Email address (MUST SUPPLY):
Home phone # :
Mobile phone # :
Drivers Licence #:
PRIOR HISTORY
All sections to be completed (attach additional sheet if required) If your offences were incurred on an interstate
drivers licence, you are required to attach a Court/Traffic History Extra ct from the relevant driving authority.
SIGNED: ___________________________________ DATE: ___ / ___ / ___
DRIVING OFFENCES
Includes Victoria / Interstate / Overseas – all infringements, penalty notices & suspensions. Do not limit your
disclosure to the last 5 or 10 years. An outline of the circumstances of each offence must be provided and your
explanation for each offence must also be included. Specific details are required, such as the % blood / alcohol
reading for any drink driving matters or specific alleged speed and if any of the offences resulted in collisions.
Details / Date / Location:
Offence Type / Penalty:
Circumstances / Explanation:
POLICE INVOLVEMENTS
The location and approximate of any interview/s you have had with police concerning any offence or crime
investigation – ever. Include an outline of the circumstances and your explanation about your involvement in
these matters. Include details of any previous cautions or warnings from police and do not limit your disclosures
to the last 5 or 10 years. Include if you have been present during a police search of a house or other building
under warrant or a drugs or firearms search of a vehicle.
Details / Date / Location:
Offence Type / Penalty:
Circumstances / Explanation:
SIGNED: ___________________________________ DATE: ___ / ___ / ___
COURT MATTERS
Have you ever had any previous court matters or do you have any matters pending. Include all results – eg
fines, diversions, convictions and findings of guilt. Any previous / current intervention orders if you were
the defendant. Describe the circumstances and ex plain your involvement in these matters.
Details / Date / Location:
Offence Type / Penalty:
Circumstances / Explanation:
BANKRUPTCY
Do you have current bankruptcy proceedings pending against you or have you ever been declared bankrupt –
voluntarily or otherwise. Your information should include the $ amounts involved & full circumstances
including the relevant dates if you have since been discharged from bankruptcy.
Details / Date / Location:
Offence Type / Penalty:
Circumstances / Explanation:
SIGNED: ___________________________________ DATE: ___ / ___ / ___
Any other details you feel may assist in your assessment:
Please note:
Ensure to complete this form in a thorough and comprehensive manner. Failure to do so may
result in a false assessment. Whilst this document is a voluntary disclosure form, any blatant
inconsistencies or untruths may add weight to future character and reputation assessments.
