Section 1: Personal Information

Please select appropriate box only:*
Filed Required
Please specify if other
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Which company/site will you be working on?*
Field Required
Is this a renewal check?*
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Names by which I am, or have been, known

Name History
Filed Required
Surname*
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First Name*
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Middle Name
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Date of birth*
/ /
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Sex*
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Place of birth

Suburb/Town
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State/Territory*
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Country*
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Permanent residential address over the last five years

If full details are unavailable, include as much information as possible.

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Number/Street
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Suburb/Town
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State/Territory
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Postcode
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Country*
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Contact details

Mobile*
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Phone (Work)
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Phone (Home)
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Email*
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Other details (if applicable)

Australian driver’s licence no
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Issued by
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Firearms licence no
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Issued by
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Section 2: Proof of identity

Identity Documents*
File Required
A pdf document of all your identity documents. Maximum file size 10MB

Documents must be selected from the list below

When applying for a National Police History Check, you must provide proof of your identity with this form (see Minimum Identity Requirements below). All documents must be originals or certified true copies. A certified copy means a document that has been certified as a true copy of an original by a person listed in Schedule 2 of the Statutory Declarations Regulations 1993 (Cth) which is available from http://www.comlaw.gov.au by searching for “Statutory Declarations Regulations 1993”.

Change of Name

If all documents provided for 100 points are under the same name you will not be required to provide additional ID documentation if you provide a maiden/alias name. If the 100 points provided are under two or more different names (e.g. birth certificate in maiden name and driver’s licence in married name) then further ID documents will need to be provided as evidence of a name change (e.g. Change of Name or Marriage Certificate issued by a State or Territory Registry of Birth, Deaths and Marriages, or Divorce Papers issued by the Family Court). These documents must be originals or certified true copies and DO NOT count towards the 100 Points. If you use a change of name document you must have provided the other names you have used in section 1 of this form.

Minimum Identity Requirements

You must provide:

  • at least one document from either Category A or Category B, that is, you do not need to provide documents from both categories as long as all other minimum requirements are satisfied;
  • at least one of your identity documents must contain a photograph. If you are unable to provide a listed document containing a photograph you must submit a passport style photograph of yourself certified by a person listed in Schedule 2 of the Statutory Declarations Regulations 1993 (Cth);
  • the combination of documents supplied should, as a minimum equal a total of 100 points; and
  • evidence of your full name and date of birth.
Category A—Each document is worth 70 points
- Birth Certificate
- Australian Passport (current, or expired within the previous two years, but not cancelled)
- Australian Citizenship Certificate
- International Passport (current, or expired within the previous two years, but not cancelled)
-Other document of identity having same characteristics as a passport e.g. diplomatic/refugee (Photo or Signature)
Category B—The first document is worth 40 points and each additional document is worth 25 points
-Current Licence or Permit (Government Issued)
- Working With Children/Teachers Registration Card
- Aviation Security Identification Card/Maritime Security Identification Card
- Public Employee Photo ID Card (Government Issued)
- Department of Veterans’ Affairs Card
- Centrelink Pensioner Concession Card or Health Care Card
- Current Tertiary Education Institution Photo ID
- Reference from a medical practitioner (must have known the Applicant for a period of at least 12 months)
Category C—Each document is worth 25 points
- Birth Extract
- Foreign/International Drivers Licence
- Proof of Age Card (Government Issued)
- Medicare Card/Private Health Care Card
- Council Rates Notice
- Property Lease/Rental Agreement
- Property Insurance Papers
- Australian Tax Office Assessment
- Superannuation Statement
- Seniors Card
- Electoral Roll Registration
- Motor Vehicle Registration or Insurance Documents
- Professional or Trade Association Card
If relied upon, the following documents must be from different organisations:
- Utility Bills (e.g. Telephone, Gas, Electricity, Water)
- Credit/Debit Card
- Bank Statement/Passbook
Special provisions only to be used if minimum identity requirements above cannot be met - Each document is worth 100 points
Applicant Category Document
Recent Arrival - have been in Australia for 6 weeks or less Current passport and proof of date of arrival
Aboriginal people, Torres Strait Islander people or resident in a remote area/community Please complete the National Police Checking Service (NPCS) Proof of Identity (Special Provision) for Aboriginal and Torres Strait Islander People and attach it to this document
Child under 18 Please provide one of the following documents:
- Birth Certificate/Birth Extract
- Australian Passport (current, or expired within the previoustwo years, but not cancelled)
- Australian Citizenship Certificate
- International Passport (current, or expired within the previous two years, but not cancelled)
- Other document of identity having same characteristics as a passport eg. diplomatic/refugee (Photo or Signature)
- Statement from an educational institution, signed by the Principal or Deputy Principal, confirming that the child attends the institution (statement must be on the institution’s letterhead)

Section 3: Accredited Organisation Details

Accredited Organisation (Legal name): The Chamber of Minerals and Energy of Western Australia Inc.

ABN: 82 738 249 529

Address: Level 10, 2 Mill Street, Perth WA 6000

Section 5: Authorisation to disclose personal information

Is the result of the National Police History Check to be forwarded/disclosed only to the Accredited Organisation named in section above?
Filed Required

If No: I authorise the result of the National Police History Check to be forwarded/disclosed to the following employer/ organisation to assess my suitability:

Employer/Organisation (Legal name)
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ABN
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Section 6: Purpose of the national police history check

Provide details of the purpose for which the check is required. Such as relevant position/role, place of work and whether you have contact with vulnerable groups e.g. Client Services Officer in a call centre, janitor at a school, volunteer in aged care facility with direct care of disabled and aged persons.

Purpose or Role
Filed Required

Section 7: General Information

Please read the General Information here

Section 8: Consent To Obtain Personal Information

Are you under 18 years of age ?
Filed Required
Parent/Guardian full name
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Filed Required