Informed Consent Form National Police Checking Service Page 3
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5INFORMED CONSENT FORM
NATIONAL POLICE CHECKING SERVICE
SPECIAL PROVISIONS ONLY TO BE USED IF MINIMUM IDENTITY REQUIREMENTS ABOVE CANNOT BE MET
Applicant Category
Document
Points Value
Points Scored
Recent Arrival - have been in
Current passport and proof of date of arrival
100
Australia for 6 weeks or less
Aboriginal people, Torres Strait
Please complete the National Police Checking Service (NPCS)
Islander people or resident in a
Proof of Identity (Special Provision) for Aboriginal and Torres
100
remote area/community
Strait Islander People and attach it to this document
Child under 18
Please provide one of the following documents:
• 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
100
previous two years, but not cancelled)
• Other document of identity having same characteristics as a
passport eg. diplomatic/refugee (Photo or Signature)
• 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)
TOTAL POINTS
Total points
scored
VERIFICATION (OFFICE USE ONLY)
NOTE: To be completed by the Accredited Organisation or its Customer (as defined in the Australian Criminal Intelligence Commission
Terms of Service).
I declare that I have sighted the Applicant’s original or certified true copy of documents and that the Applicant has met the Minimum
Identity Requirements above. I am satisfied as to the correctness of the Applicant’s identity.
Signature
Printed name
/
/
Date
SECTION 3: ACCREDITED ORGANISATION DETAILS
Accredited Organisation
NSW DEPARTMENT OF EDUCATION
40 300 173 822
(Legal name)
ABN
22 Main Street Blacktown NSW 2148
Address
SECTION 4: ACCREDITED ORGANISATION NOTES (OFFICE USE ONLY)
Notes
SECTION 5: AUTHORISATION TO DISCLOSE PERSONAL INFORMATION
Is the result of the National Police History Check to be forwarded/disclosed only to the Accredited Organisation named in Section 3 above?
Yes
No 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:
Employer/Organisation
(Legal name)
ABN
3
Version 3.0
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