STATUTORY DECLARATION

Statutory Declarations Act 1959

I make the following declaration under the Statutory Declarations Act 1959:

QUESTION 1:

I declare that (place a tick or cross in applicable box):

QUESTION 2:

I declare that (place a tick or cross in applicable box):

Please refer to this definition when answering below. A disclosable outcome includes:

• convictions of murder or sexual assault
• convictions of theft or fraud
• convictions of, and sentenced to imprisonment for, any other form of assault
• findings of guilt
• terms of imprisonment longer than thirty months
• violent or sexual offences
• information where the release would be in the interests of crime prevention and public safety
• finding of guilt without conviction and/or imposition of good behaviour bond charges or any other outstanding matter under investigation that have not yet proceeded to court
• an indictable offence which is an offence against a law of Commonwealth or a State or Territory or and offence against a law of a foreign country that corresponds to an offence against a law of the Commonwealth or a State or Territory

 

QUESTION 3:

I declare that (place a tick or cross in applicable box):

I confirm I have :

a) been given an opportunity to have this document explained to me by another person,or translated into a language other than English (if required);

b)read and understand the position description provided to me and description of hazards identified above; and

c)read and understand the requirements and consequences associated with the disclosure I am asked to make; and

d) confirm that the disclosure I have made above is correct and free of false or misleading information

 

I understand that a person who intentionally makes a false statement in a statutory declaration is guilty of an offence under section 11 of the Statutory Declarations Act 1959, and I believe that the statements in this declaration are true in every particular.