Informed Consent Form Dcsi Screening Unit Child-Related Employment Screening
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5Informed Consent Form
DCSI Screening Unit
Child-related Employment Screening
Forms lodged at Australia Post will incur a $62.20 fee (GST
incl.) for paid employees and a $42.40 fee (GST incl.) for
volunteers.
Failure to complete your form in accordance with
instructions may result in your form being returned.
*2861 A1 AUSTRALIA POST 01 – VERSION A1
Part A: Your Personal Details
Title:
Last name:
Student ID:
(where applicable)
First name(s):
Preferred name:
Previous names:
(include ALL names by which you have been known, eg a maiden name, deed poll changes, aliases)
Last name:
First name(s):
Last name:
First name(s):
Last name:
First name(s):
Gender:
Male
Female
Date of birth:
Town/city of birth:
State of birth:
Country of birth:
Passport No:
Country of issue:
Driver’s Licence No:
State of issue:
Are you (or do you identify as) Aboriginal or Torres Strait Islander?
Yes
No
Current residential address:
Suburb/town:
State:
Postcode:
Period of residence:
From:
To:
Telephone:
(H)
(W)
(M)
Email address:
Current postal address (if different from above):
Suburb/town:
State:
Postcode:
Current Employer/Contractor:
(Govt contractors only)
DCSI Screening Unit use only
Date entered:
Entered by:
L clear:
C clear:
nd
CC clear:
2
:
C1 | DCSI Screening Unit screening@dcsi.sa.gov.au 1300 321 592
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