Application Form For Volunteer National Police Check

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APPLICATION FOR VOLUNTEER NATIONAL POLICE CHECK
This is not an application for a National Police Certificate
Part A:
Personal Details (To be completed by volunteer)
(See page 2 for instructions for completing this form and further information)
SURNAME: ________________________________
GIVEN NAMES: _____________________________________
PREVIOUS, MAIDEN OR ALTERNATIVE NAMES: ___________________________________
DATE OF BIRTH: ___________________
MOTOR DRIVERS LICENCE NUMBER: ______________ STATE OF ISSUE: ________
(If applicable)
HAS A WORKING WITH CHILDREN CARD APPLICATION BEEN SUBMITTED?
YES/NO
Working with Children Application Number
Part B:
Statement of Consent and Indemnity (To be signed by volunteer)
I consent to a check of the records of all Australian Police jurisdictions and to the acknowledgement of the existence of any court
outcomes and/or pending charges being provided to an approved volunteer group.
In consideration of WA Police releasing an acknowledgment of any court outcomes or pending charges, under this application,
I hereby indemnify the state of WA, its servants and agents including all members of WA Police against all actions, suits,
proceedings, causes of actions, costs, claims and demands whatsoever which may be brought or made against it or them by any
body or person by reason of or arising out of the reason of any details of any court outcomes and other information recorded
against my name purporting to either relate to or concern me.
VOLUNTEER’S SIGNATURE __________________ DATE______________
Part C
Checklist (To be completed by representative of volunteer group)
Volunteer’s personal identification checked
YES
Working with Children Application Sighted if applicable
YES
I, being a representative of the following volunteer group, request a Volunteer Police Check and confirmation as to whether the
above named volunteer has any court outcomes and/or pending charges.
The individual’s proof of identity has been checked and I confirm that the individual volunteer is in fact the person named in this
form.
Any information received will be treated confidentially and used for the sole purpose of screening volunteers. This information
will not be released to any third party.
I confirm that the above named will be conducting volunteer work within the set criteria for this scheme.
NAME OF VOLUNTEER GROUP ___________________________________________
REPRESENTATIVE’S NAME AND SIGNATURE___________________________
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