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Nationally Coordinated Criminal History Check - Summary Sheet

This document provides instructions for applying for a Nationally Coordinated Criminal History Check. It outlines how to submit the signed application form along with copies of identification and payment. The applicant's personal details are listed, including name, date of birth, address, and the four forms of identification being submitted. Payment details are also noted, showing the fee paid, payment date, and receipt number. The applicant signs to consent to the criminal history check and release of information. Spaces are provided for photograph and identity verification by an authorized person.

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Jonny
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154 views1 page

Nationally Coordinated Criminal History Check - Summary Sheet

This document provides instructions for applying for a Nationally Coordinated Criminal History Check. It outlines how to submit the signed application form along with copies of identification and payment. The applicant's personal details are listed, including name, date of birth, address, and the four forms of identification being submitted. Payment details are also noted, showing the fee paid, payment date, and receipt number. The applicant signs to consent to the criminal history check and release of information. Spaces are provided for photograph and identity verification by an authorized person.

Uploaded by

Jonny
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Nationally Coordinated Criminal History Check – Summary Sheet

How to Lodge your Application


1. Print and sign this Summary Sheet;
2. Pay for your Nationally Coordinated Criminal History Check – if you did not pay online via credit card, you may include a Cheque or Money
Order when lodging this signed Summary Sheet. Cash payments can only be made in person to the Screening Unit at the Department of
Education;
3. Lodge this signed Summary Sheet, together with copies of your 4 items of identification by one of the following ways:
By Post In Person By Email
ONLY accepted when Photograph & Identity Screening Unit, ONLY accepted when Photograph & Identity
Verification section completed. Post to: Department of Education, Verification section completed. Email to:
Screening Unit, Department of Education, 151 Royal Street, East Perth, WA, 6004 [email protected]
Locked Bag 2, East Perth, WA, 6892 (Please bring Original ID)

Your Details
Surname CHEN Date of Birth 24/10/1981 MALE
Given Name/s JONATHAN WEI SHAN Phone 0499 073 313
Address 7/53 OSWALD STREET Prospective Employer CATHOLIC EDUCATION
INNALOO WA 6018 Worksite LA SALLE COLLEGE
Identity 6917892 - WA Role/Position TEACHER

Your Four (4) Identity Documents to Send


 Copy of Certificate of Residency - Australian Government  Copy of Driver's Licence - Australian
 Copy of Medicare card  Copy of Tertiary Student ID card with photo

Payment
Fee: $46.00 Payment Method: Credit Card
Payment Date: 15/02/2019 6:51:45 PM EST Receipt Number: 91223847919

Consent & Declaration


I hereby certify that I am the applicant named in this form and all details herein have been provided by me and are true and correct. I acknowledge that I have read and
understood the contents of this form and the information associated with this form. I consent to a check of the records of all Australian police jurisdictions and to the release
of any other convictions, findings of guilt, either with or without convictions, including convictions that have been declared ‘spent’, and any matters still outstanding as well as
other matters deemed to be relevant by the Australian Criminal Intelligence Commission (ACIC) which are recorded against me. I further consent to the release of any
associated Statement of Material Facts from the Western Australian Police to the Department about any convictions recorded against my name that are deemed relevant as
part of this probity assessment.

D D M M Y Y Y Y

Signature of Applicant Date Signed

Photograph & Identity Verification


To be completed by the School, TAFE college, University, Accredited Body, or an authorised person listed in the Statutory Declarations Regulations 2018 Schedule 2
(https://www.legislation.gov.au/Details/F2018L01296) as defined in the Australian Criminal Intelligence Commission Agreement:
I declare that I have sighted the Applicant’s Identification documents, as listed above, and the Applicant’s identity has been confirmed via face-to-face comparison with
photographic identification. I am satisfied as to the correctness of the Applicant’s identity.

Verifier Name Verifier Position/Job Verifier Phone Number

Verifier Signature Verifier Employer D D M M Y Y Y Y

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