National Criminal Record Check Consent Papers Page 3

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APPLICANT DECLARATION AND EMPLOYMENT SCREENING
CHILD RELATED EMPLOYMENT
CONSENT FOR
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
Family Name
First Given Name
Given Name 2
Given Name 3
Primary Name
Maiden Name
(if applicable)
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:
Title of Child Related
(specify its child-related nature eg ‘child care assistant’, not ‘assistant’)
Position
Paid Employee
Contractor
Type of Position
Volunteer providing intimate personal care to disabled children
Volunteer providing mentoring to disadvantaged children
(Please tick)
Minister, priest, rabbi, mufti or other like religious leader or spiritual officer of a religion or
other member of a religious organisation
Licensee for prescribed children’s services
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
It is an offence for a prohibited person to apply for, attempt to obtain, undertake or remain in child-related
employment, or to sign this declaration.
A prohibited person is a person who is convicted of the following (whether in NSW or elsewhere):
murder of a child
serious sex offence, including carnal knowledge
child-related personal violence offence (an offence committed by an adult involving intentionally wounding or causing
grievous bodily harm to a child)
indecency offences punishable by imprisonment of 12 months or more
kidnapping (unless the offender is or has been the child’s parent or carer)
offences connected with child prostitution
possession, distribution or publication of child pornography; or
attempt, conspiracy or incitement to commit the above offences.
A prohibited person includes a Registrable person under the
Child Protection (Offenders Registration) Act 2000.
A conviction includes a finding that the charge for an offence is proven, or that a person is guilty of an offence, even
though the court does not proceed to a conviction.
Details of these offences and Employer Guidelines can be found online at
Guidelines/FactSheet 1]
CGRM_WCC_HS 7.2 Last Updated March 2010

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