Application to transition to Full Registration - TRBWA
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Application to transition to Full Registration This form is used to apply for Full Registration by a teacher holding Provisional or Non-Practising Registration To be eligible for the grant of Full Registration you must: hold a teaching qualification from an Australian or New Zealand accredited initial teacher education program or one recognised by the Teacher Registration Board of Western Australia (TRBWA) as equivalent; and have taught at one or more Australian or New Zealand schools for a minimum period of 100 days in the past 5 years; and be able to demonstrate that you meet the Professional Standards for Teachers in Western Australia at the Proficient Level; and be a fit and proper person to be registered. Continuance of registration for Provisional or Non-Practising Registered Teachers If your application for Transition to Full Registration is received at the TRBWA at least 28 days prior to your current registration expiring, your registration will continue until the TRBWA finalises your application, even if your registration is scheduled to expire beforehand. If your application is received less than 28 days before the expiry of your current registration, the above provision does not apply and your registration may expire prior to your application being finalised. Although the TRBWA will endeavour to process your application in a timely manner, it cannot guarantee that your application will be finalised prior to the expiry of your registration period. 2014/09239 Transition to Full Registration Issued 08/02/2021 Uncontrolled when printed Page 1 of 13
Personal details (please print clearly) Current registration number and category of registration: ________________ () Provisional Registration Non-Practising Registration Title Dr Mr Mrs Ms Miss Other_______________ Given name Middle name(s) Family name/surname Preferred name Gender Male Female Other Date of birth (dd/mm/yyyy) / / Other names by which I am or ever have been known including: Alias (A), name change by Marriage (M) or previous name, changed by Change of Name Certificate by Department of Birth, Deaths and Marriages (P) (please beside each other name). If more room is required, list on a separate sheet. Please sign and send the sheet with this application form. Additional sheet included? Yes No A M P (Family name/surname) (Given name and other names) A M P (Family name/surname) (Given name and other names) Address Information Current postal address (No/Street) e.g. 1 Town Street Country Suburb/Town/City State Postcode Is this also your current residential address? Yes No Current Residential address (if different from postal address) (No/Street) Country Suburb/Town/City State Postcode Date resided from (dd/mm/yyyy) Contact Details Preferred contact number Mobile or Landline Mobile Landline Preferred email Alternate email PLEASE NOTE: The TRBWA will use this email address as your registered email address for contact purposes. During the application process it is your responsibility to inform the TRBWA of any changes to your contact details. 2014/09239 Transition to Full Registration Issued 08/02/2021 Uncontrolled when printed Page 2 of 13
Recent teaching experience Please provide details of your teaching experience in the table below. If possible, provide at least 5 years worth of history.If required, the TRBWA may request further information on your work history. From To Country, State or School or educational Year levels and subjects Territory venue taught / / (current) ongoing / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / 2014/09239 Transition to Full Registration Issued 08/02/2021 Uncontrolled when printed Page 3 of 13
Professional Standards for Teachers in Western Australia requirement Your application involves an assessment as to whether you meet the requirements of the Professional Standards for Teachers in Western Australia at the Proficient Level. Firstly, you must be able to demonstrate that you have taught for a minimum period of 100 days in one or more Western Australian educational venues or other Australian or New Zealand schools in the 5 years prior to application. For a definition of ‘teaching’ as defined by the Teacher Registration Act 2012, please refer to the ‘Who needs to be registered in WA?’ section of the TRBWA website. Please tick () the following if you have completed the required numbers of days teaching in Australia or New Zealand. I confirm that I have taught for a minimum period of 100 days in one or more Western Australian educational venues or other Australian or New Zealand schools in the 5 years prior to application and I understand that evidence may be requested by the TRBWA to support this declaration. If you have not taught for the minimum period of 100 days in the 5 years prior to application, you will not be eligible for the grant of Full Registration. You may, however, be eligible for extending Non-Practising Registration or the renewal of Provisional Registration if exceptional circumstances exist. Please contact the TRBWA for advice on applying for registration in the category of Non-Practising or to renew Provisional Registration, if applicable. Meeting the standards is generally based on an assessment of evidence at the school/workplace level and is verified by a declaration from an appropriate person*. The declaration must be against a range of substantive evidence and must demonstrate that all of the Professional Standards have been met. Where it has not been possible to obtain a declaration from an appropriate person, evidence may be directly submitted to the TRBWA for assessment. Circumstances where a direct submission of evidence may be accepted include, but are not limited to, casual/relief/contract teachers who teach at many schools for only limited days or have prolonged periods of non-teaching between contracts/relief days. For more information on this option, please refer to Information for Applicants – Direct Submission of Evidence found on the TRBWA website or contact the TRBWA for advice. For all applications please note, the TRBWA may require further evidence or verification where necessary, prior to making a decision on the application. Please indicate () below the method on which your application is based. ☐ Appropriate Person Declaration I have collected and retained evidence that demonstrates how I meet all the Professional Standards for Teachers in Western Australia at the Proficient Level; and I have been able to demonstrate that I meet all the Professional Standards at the Proficient Level to the satisfaction of an appropriate person. Evidence required: Please ensure that the declaration from an appropriate person (on the following pages) has been completed. ☐ Direct Submission of Evidence I have not been able to obtain a declaration from an appropriate person*. I have compiled evidence using the approved cover sheet which demonstrates that I clearly meet all the Professional Standards for Teachers in Western Australia at the Proficient Level. Evidence required: A submission of evidence compiled to demonstrate that all Professional Standards for Teachers in Western Australia at the Proficient Level have been met supported by the approved TRBWA Cover Sheet – Direct Submission of Evidence. 2014/09239 Transition to Full Registration Issued 08/02/2021 Uncontrolled when printed Page 4 of 13
*An appropriate person is: In a school, an applicant’s Principal or a person delegated by the Principal who is currently working within the same educational venue as the applicant. In an educational venue other than a school, the person who has day-to-day management responsibility (eg. in an education and care service, the nominated supervisor) or their delegate. Persons delegated responsibility as the appropriate person to determine whether an applicant meets the standards may be a Deputy Principal, head of department, experienced/senior teacher, supervisor or line manager. An appropriate person: must hold Full Registration as a teacher in Australia or New Zealand. must be in a reasonable position to assess the applicant against the Professional Standards for Teachers in Western Australia and make a declaration to the TRBWA in relation to this. In certain limited situations, a declaration may be acceptable from an appropriate person at an applicant’s previous educational venue. These situations include: - where there are no teachers holding Full Registration within an applicant’s current school/educational venue. - where a teacher applying for Full Registration is not currently working in an school/educational venue. - for child care centres. For more information please read the Professional Standards Policy, Professional Standards for Teachers in WA and the Guide to Evidencing the Professional Standards at the Proficient Level on the TRBWA website. 2014/09239 Transition to Full Registration Issued 08/02/2021 Uncontrolled when printed Page 5 of 13
Appropriate person’s declaration as to whether the applicant has met the Professional Standards I declare that (one of the following is relevant to my declaration): I. I am the Principal at the applicant’s school; or II. I have been delegated authority by the Principal at the applicant’s school; or III. I am the Nominated Supervisor in an Early Childhood setting IV. I have been delegated by the Nominated Supervisor in an Early Childhood setting AND I hold Full Registration as a teacher in Australia or New Zealand and I am in a reasonable position to assess the applicant against the Professional Standards for Teachers in Western Australia at the Proficient Level AND I confirm the applicant has demonstrated they meet all the Professional Standards at the Proficient Level and has taken into account all of the focus areas and level descriptors under each of the seven standards when evidencing them. I have provided a summary below of reasons to support this claim. Please provide a summary of the reasons why you consider that the applicant meets the Professional Standards for Teachers in Western Australia at the Proficient Level 2014/09239 Transition to Full Registration Issued 08/02/2021 Uncontrolled when printed Page 6 of 13
Please note: The TRBWA may request further information in relation to the basis of the declaration. Sign Here Signature _______________________________ Date _____/_____/____ Full name:_______________________________________ Full Registration number :____________________ State registered in (): WA ACT NSW NT QLD SA TAS VIC NZ School/Educational venue name:___________________________________________________________________ School/Educational Venue address:_________________________________________________________________ Position at school/educational venue:________________________________________________________________ Name of Principal at educational venue or person who holds a position equivalent to Principal: ______________________________________________________________________________________________ It is an offence under the Act to provide a false or misleading statement. 2014/09239 Transition to Full Registration Issued 08/02/2021 Uncontrolled when printed Page 7 of 13
Fit and Proper questions The Teacher Registration Act 2012 (Act) requires the TRBWA to have regard to certain matters to determine whether you are a fit and proper person to be registered. Read carefully before responding. It is an offence under the Act to provide false and misleading information to the TRBWA in order to gain registration. You are Yes No required to respond to the following questions (). 1. During your current period of registration, have you had registration, licensing, classification or other authority as a teacher suspended, cancelled or withdrawn in Australia or any other country for disciplinary reasons? 2. During your current period of registration, have you been subject to any conditions in practising the profession of teaching in Australia or any other country? 3. During your current period of registration, have you been refused registration, licensing or classification as a teacher in Australia or any other country? 4. During your current period of registration, have you been, or are you currently the subject of disciplinary action in response to allegations concerning incompetence as a teacher, misconduct as a teacher, or fitness to be a teacher, including preliminary investigation, either informal or formal in Australia or any other country? 5. Do you have a serious medical condition, or mental or physical impairment, that adversely affects, or is likely to adversely affect, your ability to practise as a teacher? If you have answered ‘yes’ to this question, the TRBWA needs to make a determination about the extent to which your ability to practise as a teacher is, or is likely to be, adversely affected. For further information, please refer to the Fit and Proper Policy – Medical Conditions and Impairments. Please refer to the Medical Conditions and Impairments form. 6. During your current period of registration, have you been dismissed or resigned from teaching in response to or following allegations of misconduct in Australia or any other country? 7. During your current period of registration, have you used any illicit drugs or engaged in any substance abuse? 8. During your current period of registration, have you been convicted of any offences (including criminal and traffic) in any overseas country? 9. Do you have any unresolved criminal charges in any overseas country? If you have answered YES to any of these questions, you must provide FULL details in a sealed envelope marked ‘Private and Confidential’ and posted to: Director, Fit and Proper Assessment Teacher Registration Board of Western Australia PO Box 3019 EAST PERTH WA 6892 This may include: responses to additional questions if you answered ‘Yes’ to question 5; a detailed submission from you as to how the events arose, what allegations were made, any findings against you, and what you have done since; a Statement of Material Facts if appropriate; character references (particularly where the referee knows about the events leading to this situation); documentation showing an outcome of the matter. Please provide sufficient information to assist the Board with their assessment of whether you are a fit and proper person to be registered. 2014/09239 Transition to Full Registration Issued 08/02/2021 Uncontrolled when printed Page 8 of 13
National criminal history checks As part of the assessment by the TRBWA as to whether you are a fit and proper person, consideration is given to any criminal history you may have, pursuant to section 24(c) of the Act. You are required to consent to the TRBWA completing a national criminal history check. Consent is provided by completing a Nationally Coordinated Criminal History Check Application and Informed Consent Form, which is found at the end of this application form and can also be found on the TRBWA website (trb.wa.gov.au). Proof of identity requirements You are required to provide four identity documents with your consent for a national criminal history check. The combined identity documents must contain your full name, date of birth and a photograph. If your identity documents do not include a photograph you must submit a passport-style photograph certified by a person listed in the ‘Authorised Third Parties for the Verification of Identity’ information sheet. Please refer to the Nationally Coordinated Criminal History Check Application and Informed Consent Form for a list of documents required for the national criminal history check. Change of name If you provide identity documents using a former name, you must provide evidence of your name change. This means providing a change of name certificate issued by the Australian Registry of Births, Deaths and Marriages or an Australian marriage certificate issued by a state or territory, in addition to your four identity documents. Church or celebrant-issued certificates are not accepted. Please note, any other name variations may require evidence to support the change of name. Special provisions for proof of identity There may be circumstances in which an applicant may not be able to meet the minimum proof of identity requirements. If you are unable to provide the minimum identity requirements, as listed on the Nationally Coordinated Criminal History Check Application and Informed Consent Form (found at the end of this application form), please contact the TRBWA who will assess your ability to meet the requirements and determine the most suitable method. Please email info@trb.wa.gov.au Verification of identity As part of the process to undertake a national criminal history check, the TRBWA is also required to verify the identity of the person making the application. This involves the comparison of the original photographic identification document provided as part of the application process with a visual comparison of the applicant. Verification for applicants submitting a paper application form, will be undertaken by either one of the following methods: via online video call, or in person at the TRBWA office. To verify your identity, you will be required to present the original photographic identification document for comparison. If the TRBWA is unable to establish that an applicant is the person represented in the application, additional photographic identification may be requested. If you are unable to undertake the identification verification process through either of the methods outlined above, please email info@trb.wa.gov.au detailing your circumstances. Please note, the verification process through either method is undertaken on an appointment only basis. Identification verification process Please tick () the appropriate option listed below. Via online video call I will verify my identity, by presenting the original photographic identification document used in my application, via an online video call. Please note, you will be sent an email requesting that you make an appointment for an online SKYPE video call to verify your identity. The email will guide you to an online booking system where you can book an appointment. You will be required to create a SKYPE account (if you do not already have one), which includes downloading and installing appropriate software. This software will work on most portable devices that have a camera, such as an iPad, 2014/09239 Transition to Full Registration Issued 08/02/2021 Uncontrolled when printed Page 9 of 13
iPhone, Android tablet, Android phone and computer. More information is available at www.skype.com or via the app stores for Android and Apple devices. Interviews are available between 8.45am and 4.00pm Monday to Friday (except public holidays). In person I will verify my identity, by presenting the original photographic identification document used in my application, at the TRBWA office. Please note, you will be sent an email requesting that you arrange a time to attend the TRBWA office to verify your identity. The email will guide you to an online booking system where you can book an appointment. The TRBWA office is located at 151 Royal Street, East Perth, Western Australia. Interviews are available between 8.45am and 4.00pm Monday to Friday (except public holidays). Please note your application will not be finalised until this process has been completed. Overseas criminal history checks (from a country other than Australia) As a registered teacher, you are required to provide an overseas criminal history check (OCHC) from every country you have resided in for a cumulative1 period of 12 months or more, from 18 years of age, during your current period of registration. Yes No Have you resided in any country other than Australia for a cumulative 1 period of 12 months or more, from 18 years of age, during your current period of registration? If you have answered ‘No’, please proceed to the Registration Obligations section. If you have answered ‘Yes’, please proceed with the requirements below for obtaining an overseas criminal history check. Obtaining an overseas criminal history check from fit2work To obtain an OCHC you must apply directly to fit2work the approved provider of OCHCs for the TRBWA. OCHCs issued by other providers will not be accepted. You can apply for an OCHC online at: https://fit2work.com.au/PreEmployment.aspx?id=trbwa. This link can also be accessed from the TRBWA website (trb.wa.gov.au). You can check on the progress of your fit2work OCHC at any time, by logging onto fit2work. Once completed, the result of your OCHC will be emailed to you and also provided directly to the TRBWA. Please note, your fit2work OCHC application is separate to your teacher registration application. Payment for your OCHC must be made directly to fit2work. If you have any questions regarding your fit2work OCHC application, please contact: fit2work tel: 1300 525 525 email: ichc@fit2work.com.au If fit2work does not conduct a check for the country you resided in, the TRBWA may accept a statutory declaration. Please contact the TRBWA to request a statutory declaration. Please do not provide your own statutory declaration or obtain one from Australia Post. 1 Cumulative – the total time spent in each individual country within your current period of registration Example - If you currently hold Full Registration which was last renewed in 2016, and you spent 6 months in the UK in 2018 and another 6 months in 2019, the total time spent in the UK would be 12 months within your current registration period. You would, therefore, be required to provide an OCHC from the UK when you apply to renew your registration in 2021. 2014/09239 Transition to Full Registration Issued 08/02/2021 Uncontrolled when printed Page 10 of 13
Overseas criminal history checks table In the table below, please list every country, other than Australia, you have resided in for a cumulative1 period of 12 months or more, from 18 years of age, during your current period of registration. For every country, please identify whether you are: 1) supplying an OCHC from fit2work with your application 2) currently in the process of obtaining an OCHC from fit2work 3) submitting a statutory declaration to the TRBWA, as an OCHC is not available from fit2work for that country (1) (2) 3) I have applied for and been I am currently in the I have checked the issued an OCHC for this country process of obtaining an list at by fit2work. A copy of this OCHC OCHC from fit2work for https://fit2work.com. will be provided directly to the this country. Once issued, au/PreEmployment.a Country TRBWA by fit2work. a copy of this OCHC will be spx?id=trbwa. and provided to the TRBWA by Fit2 work do not fit2work. provide an OCHC for this country. * Date issued Reference If Yes, tick () below (DD/MM/YYYY) number *If fit2work does not conduct a check for the country you resided in, the TRBWA may accept a statutory declaration. Please contact the TRBWA to request a statutory declaration. Please do not provide your own statutory declaration or obtain one from Australia Post. NOTE: A statutory declaration has to be received in hard copy 1 Cumulative – the total time spent in each individual country within your current period of registration Example - If you currently hold Full Registration which was last renewed in 2013, and you spent 6 months in the UK in 2016 and another 6 months in 2017, the total time spent in the UK would be 12 months within your current registration period. You would, therefore, be required to provide an OCHC from the UK when you apply to renew your registration in 2018. 2014/09239 Transition to Full Registration Issued 08/02/2021 Uncontrolled when printed Page 11 of 13
Registration obligations Registration as a teacher carries with it a number of obligations. I understand it is a requirement for me to: maintain my teacher registration which includes the requirement to pay an annual fee by 31 March each year provide notice to the Board if I have a change of name, postal or email address within 30 days of these changes occurring (noting that failure to comply with this requirement may result in a penalty fine to the maximum of $1,000). provide written consent to the TRBWA, upon request, to obtain a criminal history check comply with any conditions placed on my registration continue to be a fit and proper person to be registered provide written notice to the TRBWA, under sections 38, 39 and 40 of the Teacher Registration Act 2012 (Act): o of any civil proceedings which result in orders to pay damages or compensation (within 30 days) o if I am convicted of an offence which includes a statutory penalty of imprisonment (within 30 days) o about any loss of my qualifications (within 30 days) o if I receive a working with children interim negative notice or negative notice (within 14 days) noting that I may commit an offence if I fail to notify the TRBWA within the time specified which could result in a penalty fine to the maximum of $5,000. Further information about your obligations as a registered teacher can be found on the TRBWA website. Department of Education consent (recommended) If you provide consent, please tick () the following: I consent to the TRBWA disclosing details, to the Western Australian Department of Education, the date on which the TRBWA determines that I am a fit and proper person to be a registered teacher. Applicant’s declaration I, ______________________________________________________________________________________ Full name of _____________________________________________________________________________________, Address sincerely declare that the information I have provided in this application is complete, true and correct, and I understand my obligations as a registered teacher. Sign Here Signature _______________________________ Date _____/_____/___ It is an offence under the Act to provide a false or misleading statement. 2014/09239 Transition to Full Registration Issued 08/02/2021 Uncontrolled when printed Page 12 of 13
To avoid unnecessary delays please check that your application is complete using the following checklist: I have completed the Nationally Coordinated Criminal History Check Application and Informed Consent Form. I have provided copies of sufficient identification documents required by the Nationally Coordinated Criminal History Check Application and Informed Consent Form. I have provided evidence supporting any change of names reflected in my application e.g. Marriage or Change of Name Certificate issued by a State or Territory Registry of Births, Deaths and Marriages I have included with this application supporting evidence relating to my application to fit2work for a criminal history check from a country outside Australia (where applicable). I have included a completed appropriate person’s declaration or I have completed the requirements to make a direct submission of evidence. Lodging this application for registration By email This application form and supporting evidence may be emailed to the TRBWA at: info@trb.wa.gov.au. In the subject line of the email please include the application category, your full name and registration number. In the main body of the email, please detail all attachments that have been included with the application. If submission by email is not practicable, please contact the TRBWA. 2014/09239 Transition to Full Registration Issued 08/02/2021 Uncontrolled when printed Page 13 of 13
NATIONALLY COORDINATED CRIMINAL HISTORY CHECK 2019 MODEL APPLICATION AND INFORMED CONSENT FORM Information about this form Privacy notice Terms used in this form How will my information be used? Nationally coordinated Describes both: the checking process The ACIC and Australian police agencies criminal history check undertaken by the ACIC and police, and the The ACIC and Australian police agencies use the information on result received by the accredited body. this form and the applicant’s identity documentation: Commonly known as a ‘police check’. to disclose police information relating to you, to the You/the applicant Individual seeking a nationally accredited body named in question D1. coordinated criminal history check. to update records held about you for law enforcement, including purposes set out in the Accredited body Organisation accredited with the ACIC Australian Crime Commission Act 2002 (Cth) and responsible for submitting your nationally coordinated criminal history Accredited body check. The accredited body or its legal entity customer uses the personal Australian Criminal Australian Government agency responsible information collected in this application to request a nationally Intelligence Commission for facilitating access to nationally coordinated criminal history check and to assure itself of your (ACIC) coordinated criminal history checks. identity. Legal entity customer Organisation the accredited body may use The accredited body may have a legislative basis for the to collect your application, including your collection, use and disclosure of your personal information and informed consent. This may be your police information to a third party. If applicable, third parties are employer, benefits provider or issuing body. listed in question D1. The ACIC recommends you seek more information about relevant legislation from the accredited body. Third party Organisation the accredited body is required by law to disclose your The accredited body or its legal entity customer must advise you if personal information and police your personal information or police information will be information to. transferred or supplied to a location outside Australia, known as the permitted offshore transfer arrangement. If this applies, the Personal information Information about you, including any legal name and location of the overseas entity are listed in information contained in your identity question D1. The ACIC recommends you seek more information documents. from the accredited body listed in D1. Police information Information released as part of a nationally You can contact the accredited body for more information on how coordinated criminal history check. they handle your personal information using the contact details at the end of this section. Who completes this form? Accredited body How is my national coordinated criminal history The accredited body or its legal entity customer pre-populates this check result determined? form with information in these sections: How to submit this form, Police information is disclosed in accordance with applicable Contact details and question D1. spent conviction legislation and information release policies of the Australian Government and state and territory governments. Applicant These links may help you source information on spent convictions: You are required to provide your personal details and informed consent to complete this form. You must also provide your identity Australian Government www.legislation.gov.au documents, as detailed in Documents required. If you are less than Australian Capital Territory www.legislation.act.gov.au 18 years of age, this form must be completed by your parent or New South Wales www.legislation.nsw.gov.au legal guardian. You are completing this form to obtain a nationally Northern Territory www.legislation.nt.gov.au coordinated criminal history check. Queensland www.legislation.qld.gov.au South Australia www.legislation.sa.gov.au Tasmania www.thelaw.tas.gov.au What is a nationally coordinated criminal history Victoria www.police.vic.gov.au check? Western Australia www.legislation.wa.gov.au A nationally coordinated criminal history check is conducted with your informed consent to determine your suitability for How do I dispute my result? employment, a position of trust or as required by legislation. A If you do not agree with the results of your nationally nationally coordinated criminal history check contains your personal coordinated criminal history check, contact the accredited body information, and any relevant police information about you, or, if applicable, its legal entity customer, using the contact according to the purpose of your nationally coordinated criminal details on page 3 and tell them you want to dispute the result. history check. The accredited body or its legal entity customer accepts and escalates all disputes. 1 Version 3.0 Australian Criminal Intelligence Commission UNCLASSIFIED
NATIONALLY COORDINATED CRIMINAL HISTORY CHECK | 2019 MODEL APPLICATION AND INFORMED CONSENT FORM Providing incomplete, false or misleading d) current proof of age or photo identity card issued by an information Australian Government agency in the name of the applicant, with a signature and photo You must take reasonable steps to ensure you provide accurate, e) current shooters or firearms licence showing a signature complete and up-to-date personal information. Withholding and photo (not minor or junior permit or licence) and/or providing misleading, or false information on this form is a f) for persons under 18 years of age with no other Primary Commonwealth offence and you may be prosecuted under the Use in Community Documents, a current student Criminal Code Act 1995 (Cth).OW TO identification card with a signature or photo. If you become aware you have provided incorrect information you must contact the accredited body as soon as possible. Secondary documents a) certificate of identity issued by DFAT b) document of identity issued by DFAT Documents required c) convention travel document secondary (United Nations) issued by DFAT Minimum identity requirements d) foreign government issued documents (for example, You must provide four documents with your completed form to drivers licence) confirm your identity: e) Medicare card • one commencement of identity document to confirm your f) enrolment with the Australian Electoral birth in Australia or arrival in Australia Commission • one primary use in the community document to show the g) security guard or crowd control photo licence use of your identity in the community; and h) evidence of right to an Australian government • two secondary use in the community documents benefit (Centrelink or Veterans’ Affairs) i) consular photo identity card issued by DFAT The accredited body or its legal entity customer will use these j) photo identity card issued to an officer by a police documents to verify your identity with the personal information you force have provided on this form. The personal information contained in k) photo identity card issued by the Australian Defence your identity documents will be used to conduct a nationally Force coordinated criminal history check, as you consent to in Section D. l) photo identity card issued by the Australian Government or a state or territory government The documentation you provide must include evidence of your full m) Aviation Security Identification Card name, date of birth and a photograph of you. If a photograph is not n) Maritime Security Identification card provided on the identity documents presented, a passport-style o) credit reference check photograph certified by a person listed in Schedule 2 of the p) Australian tertiary student photo identity document Statutory Declarations Regulations 1993 (Cth) can be accepted in q) Australian secondary student photo identity addition to the four required documents. document r) certified academic transcript from an Australian Commencement documents university (a) full Australian birth certificate (not an extract or birth s) trusted referees report card) t) bank card (b) current Australian passport (not expired) u) credit card. (c) Australian visa current at time of entry to Australia as a Names resident or tourist * All names under which you have been or are currently known will (d) ImmiCard issued by Department of Home Affairs be included on the nationally coordinated criminal history check. (previously the Department of Immigration and Border If you are concerned about the disclosure of details relating to your Protection) that enables the cardholder to prove their visa previous known names, please contact the accredited body through and/or migration status and enroll in services which you are submitting your check for a nationally coordinated (e) certificate of identity issued by Department of Foreign criminal history check for assistance. Affairs and Trade (DFAT) to refugees and non-Australian citizens for entry to Australia (f) document of identity issued by DFAT to Australian Change of name citizens or persons who have the nationality of a If you provide identity documents using a former name, you must Commonwealth country for travel purposes provide evidence of your name change. This means providing a (g) certificate of evidence of resident status. change of name certificate issued by the Australian Registry of Births, Deaths and Marriages or an Australian marriage certificate * A Visa Entitlement Verification Online (VEVO) record may be issued by a state or territory, in addition to your four identity provided. If you are a New Zealand citizen on a Special Category Visa, documents. Church or celebrant-issued certificates are not you can request your VEVO details from the Department of Home accepted. Affairs via their website. Primary documents Special provisions for proof of identity a) current Australian drivers licence, learner permit or The ACIC recognises that in exceptional circumstances you may not provisional licence issued by a state or territory, showing a be able to meet the minimum proof of identity requirements. signature and/or photo and the same name as claimed Please contact the accredited body who will assess your ability to b) Australian marriage certificate issued by a state or meet the requirements and determine the most suitable method territory (church or celebrant-issued certificates are not to confirm your identity. accepted) c) current passport issued by a country other than Australia with a valid entry stamp or visa 2 Version 3.0 Australian Criminal Intelligence Commission UNCLASSIFIED
NATIONALLY COORDINATED CRIMINAL HISTORY CHECK | 2019 MODEL APPLICATION AND INFORMED CONSENT FORM How to submit this form Alias name: Smith, Lucy Jane Previous name: Jones, Lucy Jane Before submitting this form, ensure all sections are complete and that you have signed and dated the form. Primary name Family name Submit your completed form and identity documents using these instructions: First given name(s) When you are satisfied that this application and informed consent form is complete and that you have all the required identity documentation, please scan together with the Other given name(s) completed application form for teacher registration and email to: info@trb.wa.gov.au. Previous known name (if applicable) Family name Contact details You can contact the accredited body or its legal entity customer for First given name(s) more information on the nationally coordinated criminal history check process, how your personal information is handled and how you can dispute your result. Other given name(s) Accredited body Teacher Registration Board of Western Australia Name Type Maiden Alias Previous Contact details Previous known name (if applicable) Telephone: 08 9223 9100 Family name Country callers: 1300 652 911 Email: info@trb.wa.gov.au First given name(s) Legal entity customer (if applicable) Other given name(s) Contact details Name Type Maiden Alias Previous If more room is required, please list on a separate sheet, sign and attach to this form. Section A – Personal information Additional sheet attached? Yes No A1. Please read this before answering the following questions. A2. Please read this before answering the following question. You must disclose all names you have been known by throughout You must select the gender that best describes how you your life, including your primary name, name before marriage identify yourself within the community. (maiden name), and other previous names and/or alias names. All names that you submit as part of your nationally coordinated The gender details that you submit as part of your nationally criminal history check, will appear on the check result. If you are coordinated criminal history check, will be the gender that concerned about the disclosure of previous name, please contact appears on the check result. the accredited body. The ACIC’s processes are aligned with the Australian With each additional name you provide, you must include your Government Guidelines on the Recognition of Sex and family name, first given names and other given names (if Gender. If these Guidelines affect you and you would like applicable). additional information specifically regarding this, please Example: contact the ACIC directly at npcs@acic.gov.au When Lucianne was born, she was given the first name Lucianne, second given name Jane and surname of Jones. When she was Your gender married, she changed her surname to Smith. Lucianne commonly uses the name Lucy when introducing herself in the community. M (Male) As such, Lucianne has four known names—her current name, F (Female) maiden name, the alias name she used before she got married and X (Indeterminate/intersex/unspecified) the alias name she uses now. Lucianne needs to provide all four names when completing this form, as follows: A3. Please read this before answering the following questions. Current name: Smith, Lucianne Jane If you cannot provide all these details, contact the Maiden name: Jones, Lucianne Jane accredited body or its legal entity customer. 3 Version 3.0 Australian Criminal Intelligence Commission UNCLASSIFIED
NATIONALLY COORDINATED CRIMINAL HISTORY CHECK | 2019 MODEL APPLICATION AND INFORMED CONSENT FORM Your date of birth Previous residential address 3 / / Street address Your place of birth Suburb/town Suburb/town State/territory Postcode State/territory Country Dates residing at address: Country From / / To / / If more room is required, please list on a separate A4. Please read this before answering the following questions. sheet, sign and attach to this form. Provide your current and previous residential addresses for the past five years. Additional sheet attached? Yes No If you cannot provide full details, provide as much information A5. Please read this before answering the following questions. as possible. If you are unsure how to complete this section contact the organisation that gave you this form. If you have an Australian drivers licence and/or an Australian firearms licence, you must provide the licence number and the state or territory that issued your licence. Current residential address Street address If you have a foreign drivers licence and/or a firearm licence you must provide the licence number and the country that issued your licence. Suburb/town If you have a passport, you must provide the passport State/territory Postcode number and the country that issued your passport. Country Drivers licence number (if available) Dates residing at address: From / / Issued by (state/territory) Previous residential address 1 Street address Firearm licence number (if available) Suburb/town Issued by (state/territory) State/territory Postcode Country Passport number (if available) Dates residing at address: From / / To / / Issued by (country) Previous residential address 2 Street address Section B - Purpose of the nationally coordinated criminal history check Suburb/town The purpose for your nationally coordinated criminal history check State/territory Postcode helps determine what police information is disclosed on your result. Country B1. Please read this before answering the following question. Dates residing at address: For question B1, provide the following information: From / / To / / 1. position title, occupation, volunteer role or entitlement being sought 2. proposed place of work (name of organisation or type of workplace or industry) 3. location of the role (town and state/territory) 4 Version 3.0 Australian Criminal Intelligence Commission UNCLASSIFIED
NATIONALLY COORDINATED CRIMINAL HISTORY CHECK | 2019 MODEL APPLICATION AND INFORMED CONSENT FORM Acronyms must not be used – except for the state/territory. Example: Case worker, Youth Housing Facilities, Canberra, What is the check type? ACT. Standard X Example: volunteer in canteen, St Bebes, Canberra, ACT Volunteer Your position title, occupation, volunteer role or entitlement Section D – Informed consent What is informed consent? Your proposed place of work (name of organisation or type of Your informed consent is needed before an accredited body can request a nationally coordinated criminal history check for you. workplace or industry) Your informed consent means you: have read and understood the information provided in this form about how your personal information and any police information relevant to you will be handled and disclosed The location of your work (town and state/territory) provide your permission for the accredited body to request a nationally coordinated criminal history check on your behalf provide your permission for the accredited body to disclose your information to any organisation listed in D1 of this form. B2. Please read this before answering the following question. How do I provide my informed consent? For question B2, indicate whether you will have An important aspect of providing informed consent is that you supervised/unsupervised contact with vulnerable groups as understand what you are consenting to. It is important that you part of the role you are applying for. read the consent statements in question D2 and, where required, get clarification from the accredited body or its legal entity Vulnerable groups means: customer, to ensure complete understanding. You must then sign - a child, and date this form at D2, to give your informed consent. - an adult who is disadvantaged or in need of special care, support or protection because of age, disability or Important: Please read this information about question D1. risk of abuse or neglect. The accredited body is required to complete the details at D1 Contact means direct or indirect face-to-face contact, before providing the form to you. phone contact or any type of communication over the D1 provides the details of the organisations to whom your internet. personal and police information will be disclosed to. Supervision means in the presence of an adult who is In question D2, you will provide your informed consent for your responsible for the safety or care of the vulnerable person. personal and police information to be disclosed to the ACIC, Australian police agencies, law enforcement agencies, and any Unsupervised means you will not be in the presence of an organisations detailed in question D1. adult who is responsible for the safety or care of the vulnerable person. D1. Organisations to whom the applicant’s personal and police information will be disclosed Select the statement that best describes the role you are applying for: Accredited Body Accredited body (legal name) Supervised contact with vulnerable people Teacher Registration Board of Western Australia Unsupervised contact with vulnerable people X Address No contact with vulnerable people 151 Royal Street, EAST PERTH, WA 6004 Section C – Type of nationally coordinated Preferred contact details criminal history check 08 9223 9100 C1. Please read this before answering the following question. ABN You may request a volunteer check if you will hold a position 69769481770 or perform a role where you will not receive any salary, benefits or financial gain. This includes students undertaking compulsory vocational placements. Legal entity customer or related government entity Volunteer check type must not be selected for the Legal entity customer or related government entity (legal Australian Government’s Work for the Dole Scheme. name) You must be able to validate the charity organisation or volunteer position to support your selection of the volunteer type. 5 Version 3.0 Australian Criminal Intelligence Commission UNCLASSIFIED
NATIONALLY COORDINATED CRIMINAL HISTORY CHECK | 2019 MODEL APPLICATION AND INFORMED CONSENT FORM Address history check to be conducted for the purpose outlined in Section B of this form. 3. have fully and accurately completed this form, and the Preferred contact details personal information I/the applicant, have provided relates to me/the applicant, and contains the full name and all names previously used by me/the applicant. ABN 4. acknowledge that withholding and/or providing misleading or false information on this form and in any supplied identity documents is a Commonwealth offence and may lead to prosecution under the Criminal Code Act Third parties (as required by law) 1995 (Cth). Third party 1 (legal name) 5. acknowledge that personal information that I/the applicant provided on this form and on the supplied identity documents may be disclosed to the accredited ABN body named in Section D of this form (including contractors, legal entity customers, related bodies or third parties named in D1 of this form in Australia or overseas, if applicable). Third party 2 (legal name) 6. acknowledge that any information sent by mail or electronically, in relation to this form, including identity documents, is sent at my/the applicant’s risk and I/the ABN applicant, am aware of the consequences of sending information in these ways. 7. acknowledge that I/the applicant am aware that I/the applicant am providing consent for a nationally Permitted offshore transfer arrangements coordinated criminal history check to be conducted using Overseas entity (legal name) all personal information provided in this form and provided in suppled identity documents. 8. understand and consent to police information relating to Location (Country) me/the applicant, being disclosed in accordance with the purpose identified in Section B of this form, and applicable legislation and information release policies (including spent convictions legislation described in Australian Government and state or territory legislation). If more room is required, please list on a separate sheet, sign and attach to this form. 9. give consent to: Additional sheet attached? Yes No a. the ACIC and police agencies using and disclosing my/the applicant’s personal information that I/ the applicant, have provided in this form and D2. Please read this before answering the following question. personal information contained in my supplied You must provide your name, read each statement carefully identity documents to conduct a nationally and then print your name, sign and date to provide your coordinated criminal history check. informed consent. b. the ACIC disclosing the police information sourced from the police agencies to other approved bodies Applicant’s consent to submit a nationally coordinated and the accredited body named in D1 of this form. criminal history check I, c. the accredited body named in D1 of this form disclosing to the legal entity customer, third Family name parties and any permitted offshore transfer arrangements also detailed in D1, my/the applicant’s personal information and police First given name(s) information to assess my/the applicant’s suitability for the purpose identified in Section B of this form. Other given name(s) 10. acknowledge that it is usual practice for my/the applicant’s personal information and police information to be used by police agencies and the ACIC for law enforcement, including purposes set out in the Australian Crime Commission Act 2002 (Cth). 1. acknowledge that I/the applicant understand the information on this form. 2. acknowledge that the accredited body named in D1 is collecting information in this form to provide to the Australian Criminal Intelligence Commission (ACIC) and police agencies, for a nationally coordinated criminal 6 Version 3.0 Australian Criminal Intelligence Commission UNCLASSIFIED
NATIONALLY COORDINATED CRIMINAL HISTORY CHECK | 2019 MODEL APPLICATION AND INFORMED CONSENT FORM Applicant 3) Secondary use in the community document: Print name Type of document collected: Signature Name as it appears on the identity document: Date / / 4) Secondary use in the community document: Parent or legal guardian Type of document collected: (where the applicant is under the age of 18) Print name Name as it appears on the identity document: Signature Date 5) Change of name document (if applicable): / / Type of document collected: Authorised agent (person responsible for the applicant, such as a legal Previous name as it appears on the document: representative) Print name Current name as it appears on the document: Signature Date / / E3. The accredited body or its legal entity customer declares that: The correct check type has been selected for this check and they have verified the legitimacy of this claim. Section E - Office use only They are satisfied as to the applicants’ identity and have Accredited body or its legal entity customer declaration. verified the linkage between the Applicant and the claimed identity. E1. What is the nationally coordinated criminal history check category for this check? Staff member For example: Employ/probity/licence. Print name Signature E2. Collected Identity Documentation 1) Commencement of identity document: Date Type of document collected: / / Name as it appears on the identity document: Document identifier number: 2) Primary use in the community document: Type of document collected: Name as it appears on the identity document: Document identifier number: 7 Version 3.0 Australian Criminal Intelligence Commission UNCLASSIFIED
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