NCC Informed Consent Form User Guide
Contents
1. 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 ii 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 iv where applicable the Accredited Agency named in Section 3 above disclosing to the ermployer organisation named in Section 4above personal information about me to assess my suitability in relation to my employment entitlement and 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 provide in this Form may be disclosed tothe Accredited Agency named in Section 3 above including contractors or related bodies corporate located in Australia or overseas for administrative purposes and 10 acknowledge that it is usual practice for an applicant s personal information to be disclosed to Australian police agencies for them to use for i their respective law enforcement purposes including the investigation of any outstandi2. IMITIRIAIC APPLICATION CONSENT FORM ACCREDITED AGENCIES CUSTOMERS Respo nse Innovate Acmuntable National Police History Check BLOCK LETTERS and in BLACK INK here Ensure the applicant has Family Name Primary Given Names Primary printed their name here acknowledge that 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 am being considered may be ina category for which exclusions from Spent Convictions legislation apply have fully completed this Form and the personal information 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 tot the CrimTrac Agency disclosing personal information about me to the Australian police agencies i the Australian police agencies disclosing to the CrimTrac Agency from their records details of convictions and outstanding charges including findings of guilt orthe acceptance of a plea of guilty by a
3. NCC Informed Consent Form ee NATIONAL NCG GRIME CHECK User Guide NATIONAL POLICE CHECKING SERVICE NPCS CIRIIIM TIRIAIC APPLICATION CONSENT FORM ACCREDITED AGENCIES CUSTOMERS Select the appropriate R sponsie Innovative Accountable employment relationship Please select appropriate box only Segre eon Weer oeps TO b thisarenewalcheck Yes M No Names by which I am or ever have bean known inchuding Alles A name change by Marriage Ml or previous nome changeby Deed Poll P fmoreroom is required list on separate sheet signand send the sheet with this application form Additional sheet included Yes O No Ensure all names are entered including aliases Surname Given Names Primary Primary and maiden names Surname mewn Genomes Surna are Given names Gend Unknown e Male Female C ther remer amt OoOo Ensure the applicants Suburb Town State Territory v place of birth is recorded Country Ensure the applicants contact details are recorded Australian Driver s LicenceNo Issued By oOo O Firearms Licence No o O State Territory Passport No sd Passport Country Oe Passport Type F Government D UNRefugee 7 Private Include a drivers license or a passport preferably However it is nota Permanent Residential Address Over Last Five Years mandatory requirement fmoreroom is required list on separate sheet signand send the sheet with this application form Ad
4. OVISIONS ONLY TO BE USED IF 100 POINT CHECK ABOVE CANNOT BE MET The full 100 p checkis m rec For recent arrivals in Australia 6 weeks or less proof of when the applicant has been in teal cat ired t it Australia for longer than 6 weeks AEE ale ca Aboriginal person or Torres Strait Identity of applicant ordinarily resident in an isolated area Islander resident in a remote area verified by TWO persons recognised as Community community Leaders of the community to which the applicant belongs 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 Child Under 18 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 ay E Total Points VERIFICATION OFFICE USE ONLY NOTE To be completed by the Accredited Agency or its Customer as defined in the CrimTrac agreement I declare that 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 am satisfied as to the correctness of the applic
5. ant s identity Signature of authorised checking officer Printed name of authorised checking officer Date Accredited Agency Legal Name NATIONAL CRIME CHECK PTY LTD ABN 139 183 145 Is the result of the national police history check to be forwarded disclosed only to the accredited agency named in Section 3above Yes No IfNo authorise the result of the national police history check to be forwarded disclosed to the following employer organisation to assess my suitability arama Legal Name ABN Provide details of relevant position entitlement place of work and whether you have contact with vulnerable groups eg Client Services Officer in a call centre Janitor at a school Nurse in an aged care facility with direct care of disabled amp aged persons or Flight Attendant with direct care of children Position Occupation or Entitlement NATIONAL CRIME CHECK Enter the total amount of points you have witnessed The authorised officer or personnel member needs to print sign and date when they witnessed the ID here If the police history information needs to be disclosed to a 3 party organisation complete the details here Include the specific reason for check i e position job title here This will need to be duplication when completing the online portal lodgment NCC Informed Consent Form ee NATIONAL NCC CRIME GHECK User Guide NATIONAL POLICE CHECKING SERVICE NPCS CIRII
6. ditionalsheet induded Yes No if full details of previous addresses are unavailable details of town s and state s if actual dates are unavailable details of territory ies of residence will suffice year of residence will suffice reas ese E State Suburb Tentor 7 Peode Country EE Include all residential ara a arr addresses for the last 5 No Street years swb O O Pentel aa Please note the applicant No Street O will need a CURRENT Suburb Teen F Peode Australian residential address NCC Informed Consent Form SATTA CRIME CHECK User Guide NATIONAL POLICE CHECKING SERVICE NPCS CIR IIMITIRJAJC APPLICATION CONSENT FORM ACCREDITED AGENCIES CUSTOMERS Resp nave Innovative Accourtable 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 toa 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 li
7. l CRIMTRAC document that needs to remain in its original form Can I lodge the application online first then get the applicant to complete the hard copy form No The consent form is required to be completed first in its entirety prior to commencing an online portal lodgment If you need any assistance please contact us on 1800 080 095
8. ment Issued Working With Children Teachers Registration Card Your initial Secondary Documents ASIC MSIC Card will score 40 points any Public Employee Photo ID Card Government Issued additional documents will be Department of Veterans Affairs Card awarded 25 points each 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 100 points must include either 1 primary document or 1 secondary document that contains a photo of the applicant Foreign International Driver s Licence Enter in the Proof of Age Card Government Issued Medicare Card Private Health Care Card number of points in Council Rates Notice Property Lease Rental Agreement the blue boxes Property Insurance Papers Tax Declaration Superannuation Statement Seniors Card Electoral Roll Registration Motor Vehicle Registration or Insurance Documents Professional or Trade Association Card if you wish to use more than one Utility Bills ag Telephone Gas Electricity Water of these documents they must be Credit Debit Card from different organisations Bank Statement Passbook NCC Informed Consent Form User Guide NATIONAL POLICE CHECKING SERVICE NPCS CiRI IMI T R A C APPLICATION CONSENT FORM ACCREDITED AGENCIES CUSTOMERS Responsive Innovative Accourtable SPECIAL PR
9. ng criminal offences Ensure the a pp licant has Note Theinformation you provide on this Form and which the Crim Trac Agency provides to the Accredited Agency named In Section signed and dated here 3 above on receipt of the Form will be used only for the purpose stated above unless statutory obligations require otherwise Applicant s Signature Parent Guardian Signature If the applicant is under Parent Guardian name 18 ensure the parent guardian has signed and dated here NCC Informed Consent Form ee NATIONAL User Guide NCO CRIME CHECK Important Compliance Requirements 1 Ensure that you have completed consent form that has been signed and dated by the applicant before a portal lodgment is commenced 2 Ensure that 100 points of ID has been appropriately witnessed and signed off by the authorised officer personnel before a portal lodgment is commenced 3 Ensure that there is a specific reason for check and purpose contained on the application form before a portal lodgment is commenced 4 Ensure that this application form is stored in secure files or a secure electronic storage solution in its entirety NCC Informed Consent Form ee NATIONAL User Guide NCC CRIME CHECK Important FAQS Can I use the old forms No The new consent form supersedes the old one and your organisation must cease using old forms Can I modify the new informed consent forms No The new consent forms are an officia
10. sted in Schedule 2 of the Statutory Declarations Regulations 1993 Cth and is available from http wwew comlaw gov au by searching for Statutory Dedarations 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 doaument you must provide in Section 1 the other names you have used Document Type Document Points Scored 100 points must include ONE Primary Document o at least ONE Secondary Document which must contain a photograph 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 Only one form of identification accepted from this category SECONDARY Current Licence o Permit Govern
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