Pd267 - National Police Check Application Form - South Australia Police

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South Australia Police
National Police Check Application
Please complete page 1 of form online before printing. *Denotes mandatory field
-
Enquiries: Information Services Branch (T) 08 7322 3347
GPO Box 1539 Adelaide SA 5001
APPLICANT DETAILS
Print Form
Family Name*
First Given Name*
Other Given Name(s)
Specify Other Name Type
Maiden
Previous
Alias
Note: if you have more than one previous name,
list on a separate sheet and attach to application
Other Family Name
Other First Given Name
Other Given Name(s)
Current Residential Address*
Suburb/Town
State
Postcode
SA
Postal Address
(NPC will be posted to this address)
Suburb/Town
State
Postcode
Previous Address
Suburb/Town
State
Postcode
Birth Place - Town/City*
State*
Country*
Home Telephone
Work Telephone
Mobile Telephone
Driver's Licence No.
State
Date of Birth* (DD/MM/YYYY)
Gender*
/
/
Male
Female
PURPOSE OF CHECK:
Purpose must be clearly stated e.g. Aged Carer, Youth Leader, Contractor in Schools, Visa.
Generic descriptions i.e. 'Employment', 'Work', 'Uni Placement' are not accepted.
CATEGORY
Employment/Probity/Licensing
Working with Children/Vulnerable Groups
*
Visa
Access to National Security Information
CHECK TYPE
Individual (I)
Individual Concession (IC)
Volunteer (VP)
*
VOAN Volunteer (VC)
Core Check (CR)
Government (EG)
FINGERPRINTS
(Only Livescan prints accepted)
Livescan Fingerprints required (additional fee)
Livescan Reference Number:
NPC and Fingerprints must be paid for together.
Livescan Reference number must be recorded on this form.
Refer NPC FAQ's for Livescan locations and additional Fingerprint information.
PD267
Revised: 12/09/2011
Page 1 of 2

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