NPCS

Section 1: Personal Information




Please select appropriate box only:**

Filed Required

Please specify if other*

Filed Required

Which company/site will you be working on?**

Field Required

Is this a renewal check?**

Field Required


Names by which I am, or have been, known




HIDDEN field for Name

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Name History*

Filed Required

Surname**

Field Required

Middle Name

Field Required

First Name**

Field Required

Date of birth**
/ /
Field Required

Sex**

Field Required


Place of birth




Suburb/Town

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State/Territory**

Field Required

Country**

Field Required


Permanent residential address over the last five years

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




HIDDEN field for Address

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Current*

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Number/Street

Field Required

From
/ /
Field Invalid

To
/ /
Field Invalid

Suburb/Town

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State/Territory

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Postcode

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Country**

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Contact details




Phone (Home)

Filed Required

Phone (Work)

Filed Required

Mobile**

Filed Required

Email**

Filed Required


Other details (if applicable)




Australian driver’s licence no

Filed Required

Issued by

Filed Required

Firearms licence no

Filed Required

Issued by

Field Required


Section 2: Proof of identity




Identity Documents**

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

Documents required

Minimum identity requirements

You must provide four documents with your completed form to confirm your identity:

  • one commencement document to confirm your birth in Australia or arrival in Australia; and
  • one primary and two secondary documents to show the use of your identity in the community.

The accredited body or its legal entity customer will use these documents to verify your identity against the personal information you have provided on this form. The personal information contained in the identity documents you provide will be used to conduct a nationally coordinated criminal history check, as you consent to in section C.

The documentation you provide must include evidence of your full name and date of birth and a photograph of you. If the documents provided by you with this form do not include a photograph, you must also submit a passport-style photograph certified by a person listed in Schedule 2 of the Statutory Declarations Regulations 1993 (Cth).

Commencement documents

  • full Australian birth certificate (not an extract or birth card);
  • current Australian passport (not expired);
  • Australian Visa current at time of entry to Australia as resident or tourist;
  • ImmiCard issued by the Department of Immigration and Border Protection that enables the cardholder to prove their visa and/or migration status and enroll in services;
  • certificate of identity issued by the Department of Foreign Affairs and Trade to refugees and non-Australian citizens for entry to Australia;
  • document of identity issued by the Department of Foreign Affairs and Trade to Australian citizens or persons who possess the nationality of a Commonwealth country, for travel purposes; and
  • certificate of evidence of resident status.

Primary documents

  • current Australian driver licence, learner permit or provisional licence issued by a state or territory, showing signature and/or photo and the same name as claimed;
  • Australian marriage certificate issued by a state or territory (church or celebrant-issued certificates are not accepted);
  • current passport issued by a country other than Australia with a valid entry stamp or visa;
  • current proof of age or photo identity card issued by an Australian government agency in your name with photo and signature;
  • current shooter or firearm licence showing signature and photo (not minor or junior permit or licence); and
  • for persons aged under 18 with no other primary documents, a current student identification card with photo or signature.

Secondary documents

The following documents, which must not be expired:

  • certificate of identity issued by the Department of Foreign Affairs and Trade;
  • document of identity issued by the Department of Foreign Affairs and Trade;
  • convention travel document secondary (United Nations) issued by the Department of Foreign Affairs and Trade;
  • foreign government issued documents (for example driver licence);
  • Medicare card;
  • enrolment with the Australian Electoral Commission;
  • security guard or crowd control photo licence;
  • evidence of right to a government benefit (Centrelink or Veterans Affairs);
  • consular photo identity card issued by the Department of Foreign Affairs and Trade;
  • photo identity card issued to an officer by a police force;
  • photo identity card issued by the Australian Defence Force;
  • photo identity card issued by the Australian Government or a state or territory government;
  • Aviation Security Identification Card;
  • Maritime Security Identification card;
  • credit reference check;
  • Australian tertiary student photo identity document;
  • Australian secondary student photo identity document;
  • certified academic transcript from an Australian university;
  • trusted referees report;
  • bank card; and
  • credit card.

Off Site-Employees

In addition, off Site-Employees are required to provide a self portrait (selfie) photograph as part of the application. The photograph must clearly show the applicants face together with an identification document.

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.

Special provisions for proof of identity

The ACIC recognises that in exceptional circumstances you may not be able to meet the minimum proof of identity requirements. Please contact the accredited body who will assess your ability to meet the requirements and determine the most suitable method to confirm your identity.

Contact details

You can contact the accredited body or its legal entity customer for more information on the nationally coordinated criminal history check process, how your personal information is handled and how you can dispute your result.





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 4: 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 5: 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 6: General Information

Please read the General Information here




Are you under 18 years of age ?*

Filed Required


Section 7: Consent To Obtain Personal Information




Parent/Guardian full name*

Filed Required

Parent/Guardian Signature

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*

Filed Required





Applicant Signature

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