Personal Information Declaration for Security Agent Licensing

1. Your details

Application number	ELAF--ISL
Surname
Given names
Service address
Residential address
Home telephone		Work telephone
Mobile		Facsimile
Date of birth		Sex
Any other names (including birth, maiden, married, changed legally or alias names) by which you have been known

Town of birth
Country of birth	Australia Other country:

Are you an Australian citizen? Yes No

Citizenship certificate number or Australian passport number:
(If you do not know your citizenship number, please write N/K)

Passport / Identity number:
Country of issue:

Do you currently reside in Australia? Yes No

You must provide a National Police Certificate from the country in which you reside (no older than 12 months from date of application).

Have you resided overseas in the past two years? Yes No

You must provide a National Police Certificate from all countries where you have resided (excluding Australia) within the last 2 years.

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	FULL RESIDENTIAL ADDRESS (N/A for deceased)	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


FAMILY NAME	GIVEN NAMES	FULL RESIDENTIAL ADDRESS (N/A for deceased)	D.O.B. (dd/mm/yyyy)

COMMENTS:

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


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

COMMENTS:

Please supply your SPOUSE / PARTNER'S PARENTS / STEP-PARENTS details(including deceased)


FAMILY NAME	GIVEN NAMES	FULL RESIDENTIAL ADDRESS (N/A for deceased)	D.O.B. (dd/mm/yyyy)

COMMENTS:

Does your SPOUSE / PARTNER have any BROTHERS or SISTERS / STEP-BROTHERS or SISTERS / HALF-BROTHERS or SISTERS?(including deceased)
Yes No


FAMILY NAME	GIVEN NAMES	FULL RESIDENTIAL ADDRESS (N/A for deceased)	D.O.B. (dd/mm/yyyy)

COMMENTS:

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


FAMILY NAME	GIVEN NAMES	FULL RESIDENTIAL ADDRESS (N/A for deceased)	D.O.B. (dd/mm/yyyy)

COMMENTS:

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


FAMILY NAME	GIVEN NAMES	D.O.B. (dd/mm/yyyy)

COMMENTS:

3. Address History

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

Working backwards, complete the following details for each address you have resided at in the last 10 years (including intestate and overseas).

	TO
DATE (e.g. Feb/2005 to Dec/2005)		ADDRESS
	TO

COMMENTS:

4. Employment and Business Details

Are you currently employed?
Yes No

Please list your current employer/s and occupation/s below


EMPLOYER/S (e.g. Security SA Pty Ltd)	OCCUPATION (e.g. Security Guard)

COMMENTS:

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

Please provide details below

			TO
NAME OF BUSINESS (e.g. Security SA)	NAME OF PARTNERS (e.g. Jerry O'Donnell)	DATE (e.g. Jan/2003 to Feb/2005)
			TO

COMMENTS:

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

Please provide details below

			TO
NAME OF COMPANY (e.g. Security SA Pty Ltd)	NAME OF DIRECTORS (e.g. John Citizen)	DATE (e.g. Jan/2003 to Feb/2005)
			TO

COMMENTS:

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

Please list details


DATE	STATE / TERRITORY / COUNTRY	OFFENCE	OUTCOME

COMMENTS:

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

Please list details


DATE	STATE / TERRITORY	OFFENCE THAT NOTICE WAS ISSUED FOR

COMMENTS:

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

Please list details


DATE	STATE / TERRITORY	OFFENCE

COMMENTS:

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

Please list details


DATE	STATE / TERRITORY / COUNTRY	OFFENCE

COMMENTS:

Are there any pending disciplinary proceedings against you?
Yes No

Please provide details