Are you an Australian citizen?Yes No

Do you currently reside in Australia?Yes No

The information below is required by the COMMISSIONER OF POLICE

Please respond to all sections.
If address or date of birth details are not known (N/K) please give reasons in the 'comments' field.

2. Family

Please provide your PARENTS / STEP-PARENTS information below (including deceased)

					✖
FAMILY NAME	GIVEN NAMES	DECEASED	FULL RESIDENTIAL ADDRESS	D.O.B. (dd/mm/yyyy)
					✖
					✖

COMMENTS:

Do you have any BROTHERS or SISTERS / STEP-BROTHERS or SISTERS / HALF-BROTHERS or SISTERS? (including deceased)Yes No

Do you have a SPOUSE / PARTNER (whether or not he/she currently resides with you)?Yes No

Do you have any CHILDREN 18 YEARS OR OLDER ONLY? (including deceased)Yes No

Are there any OTHER PERSONS (not listed above) residing with you? (excluding persons under the age of 18 years)Yes No

3. Address History

Have you lived at any address, other than your current address, in the last 10 years?Yes No

4. Employment and Business Details

Are you currently employed?Yes No

Have you in the last 5 years operated a business in partnership, or are you currently operating in one?Yes No

Are you currently, or have you during the last 5 years, been a director of a company (other than a company listed on the stock exchange)?Yes No

5. Offence History

FAILURE TO DECLARE IS AN OFFENCE It is your responsibility to ensure accuracy. If you are in any doubt whatsoever contact the SAPOL LICENSING AND ENFORCEMENT BRANCH on (08) 7322 3342

Have you ever attended court, been charged, or reported for any offence either in Australia or overseas (include all offences committed before the age of 18, traffic offences and spent convictions)? (Expiation notices not included here - refer to next question)
Yes No

Have you ever been issued with any type of expiation notice in AUSTRALIA? (e.g. for minor traffic notices, drug, shop lifting, tobacco, liquor, environment)
Yes No

Have you been charged or reported for any offences, which have not yet been before court, or are currently before the court?Yes No

Have you been disciplined, fined or disqualified by any Tribunal, Board or other Authority (e.g. Business Licensing) in this State, other State or Territory or Country?Yes No

Are there any pending disciplinary proceedings against you?Yes No

6. Authority

I hereby consent to the release of full details of any person and any other relevant information that any Australian State/Federal/Territories Police or Law Enforcement Agency may have in its possession with reference to me. This includes any convictions imposed on me that are spent or rehabilitated (however described) under State/Territory/Federal Legislation. I acknowledge without this consent being provided, spent or rehabilitated convictions within certain States may not be disclosed.

South Australia Police (SAPOL) will release all findings of guilt, all proven court outcomes, including offences for which a `without conviction` was recorded, and expiation notices. The information is released in accordance with SA legislation.

Offences from other States/Territories will be released in accordance with their specific spent conviction and rehabilitation legislation policies.

I authorise the Commissioner for Consumer Affairs to make any enquiries that may be relevant for Security Licensing.



Click here to indicate that you have read and agree to the above 'Authority' section