National Criminal Record Check Consent Papers
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6ATTACHMENT 7.3
NATIONAL CRIMINAL RECORD CHECK CONSENT FORM
Provide your full name as well as any other names / aliases by which you have been known. Employers are required to sight
applicant’s original identifying documents as per 100 point ID check and retain copies of identification documents.
First Given
Family Name
Given Name 2
Given Name 3
Name
Primary Name
(if applicable)
Maiden Name
Complete Previous / Alias Name if any and circle the appropriate name type
Previous/Alias Name 1
Previous/Alias Name 2
Previous/Alias Name 3
Previous/Alias Name 4
Male
Female
Gender
Date of Birth
/
/
(dd/mm/yyyy)
:
Suburb/Town
Place of Birth
State:
Country:
No/Street:
Current Residential
Suburb/Town:
Address
State:
Postcode:
Country:
Postal Address
(if same as Residential Address, write
“As Above”)
No/Street:
Previous Address
Suburb/Town:
(if any)
State:
Postcode:
Country:
Email
Telephone No
Mobile:
Business:
Private:
Paid Volunteer Other
Position Applied
Type of Position
If you have used one of these documents to verify your identity, please fill in these details:
Driver’s Licence
Number:
Issuing State:
Firearms Licence
Number:
Issuing Agency:
Number:
Type:
Issuing Country:
Private Government
Passport details
UN Refugee
1.
I acknowledge that I have read the Information sheet provided with this Form and understand that the position for which I am being
considered is in a category for which NO exclusion has been granted from the application of the Spent Convictions Scheme, as
described under the heading “Spent Convictions Schemes” in the Information sheet.
2.
I certify that I am the applicant herein and that all the details that I have provided are true and correct and that I have not omitted
any Maiden Name, previous names or aliases that I have used in the past;
3.
I acknowledge that any information provided by me on this Form or by Australian Police Services as a result of the records check
may be taken into account by NSW Health in assessing my suitability for the above position.
4.
I consent to: (i) my employer forwarding details obtained from this form to NSW Health;
(ii) NSW Health forwarding details obtained from this form to the CrimTrac Agency and/or to Australian police services
or other relevant law enforcement agencies.
5.
I consent to:
(i)
the CrimTrac Agency making enquiries to Australian Police Services;
(ii)
Australian Police Services obtaining and disclosing from their records personal information about me, including any outstanding
charges, criminal convictions and findings of guilt recorded against me for any offences in any jurisdiction, that may be disclosed
according to the laws of the jurisdiction and, in the absence of any laws governing the release of that information, according to
the jurisdiction's information release policy, and forwarding relevant information to the CrimTrac Agency; and
(iii) the CrimTrac Agency providing relevant information to NSW Health for the purposes of allowing NSW Health to assess my
suitability in relation to my employment.
I am aware that if any such records are identified, NSW Health may seek additional information relating to that record from sources such
as courts, police, prosecutors and past employers. I understand that the purpose of seeking this information is to enable a full and
informed employment risk assessment and that where other information is available, NSW Health will obtain that information for
employment risk assessment purposes only. I acknowledge that any information obtained as part of this process may be used by
Australian Police Services for law enforcement purposes including the investigation of any outstanding criminal offences.
Name:
Signature:
Date:
/
/
CGRM_NCRC HS 7.3 last Updated March 2010
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