AFP NPC FORM-5021

Payment Ref No:

Consent
Notes:
Proof of IDs
NATIONAL POLICE CHECK (NPC)
Mandatory Details
APPLICATION FORM
Website: www.afp.gov.au Telephone: 02 6140 6502 Fax: 1300 549 456
Fingerprints (attached)
Enquiries: AFP-NationalPoliceChecks@converga.com.au ABN: 17 864 931 143 Fingerprints (paid)
Office Hours: 8am to 5pm, Monday to Friday (except ACT Public Holidays)

Please complete this form by referring to the Application Completion Guide. If completing manually, use BLOCK LETTERS and black ink. Mark check boxes with a cross (X).
This application form is NOT to be scanned and loaded during the online application process.

SECTION 1: Type of check required (this section must be completed - select only one)

Name Check Only (Fee: $42) Name and Fingerprint Check (Fee: $99 if fingerprints are taken and paid, $139 if not paid)

SECTION 2: Fingerprints (Optional) (complete only where fingerprints are required and/or authorised by law)
Please note that a fingerprint check is only required under very limited circumstances. Please ensure that you are actually required to have a fingerprint check conducted
before going to the expense of this level of check by checking with the organisation/department requesting the check.
Note: Fingerprints can be taken by your local police jurisdiction or the AFP. Where fingerprints are taken by the AFP and the AFP charges for this service a receipt must be
obtained and supplied to Criminal Records with this application.

Date Taken: (DD MM YYYY)

Police Station: Officer’s Name & No:

SECTION 3: Details of Applicant (this section must be completed)

Family Name / Surname :

First Name / Given Name:

Other Given Names:

Date of Birth: (DD MM YYYY)

Were you born in Australia?
Yes Suburb / Town of Birth: State:

No Country of Birth:

Daytime Contact Number:

Email Address (optional):

Australian Driver’s Licence No: Issuing State:

SECTION 4: Other names you have used (including former, maiden name/s etc)

Former Name Also known as Date of Birth: (DD MM YYYY)

Family Name / Surname :

First Name / Given Name:

Other Given Names:

Former Name Also known as Date of Birth: (DD MM YYYY)

Family Name / Surname :

First Name / Given Name:

Other Given Names:

Note: If you need to record additional names please use Attachment B. Page 1 of 5
 AFP NPC FORM-5022

SECTION 5: Current & Previous Residential Addresses (this section must be completed)
Current Residential Address (must not be a PO Box or Business Address)

Unit No / Street No /
Street Name:

Suburb / Town / Locality:

Postcode: State:

Country:

Date you started living at this address: (DD MM YYYY)

In the event you have not resided in your current location for 10 years or greater, please provide details of your previous residential addresses.
Previous Residential Address (must not be a PO Box or Business Address) - Note: To record additional addresses please use Attachment C.

Unit No / Street No /
Street Name:

Suburb / Town / Locality:

Postcode: State:

Country:

Date you started living at this address: (DD MM YYYY)

SECTION 6: Mailing Address for Police Certificate

This can be a PO Box or Business Address. Note: If not completed, the certificate will be sent to the applicant at the Current Residential Address specified
in Section 5.
(optional) I authorise the Police Certificate to be forwarded to the following person/organisation

Attn. To / Organisation:

Unit No / Street No /
Street Name:

Suburb / Town / Locality:

Postcode: State:

Country:

SECTION 7: Payment Details (this section must be completed)

Credit Card/Debit Card (please complete card details below) Bank Cheque Money Order

Cardholder’s Name:

Credit Card Number:

MasterCard Debit Card MasterCard Credit Card Visa Debit Card Visa Credit Card Amex
(Surcharge: 0.242% 0.539% 0.506% 1.023% 1.595%)

The CVC Number is a 3 digit number on the back of your VISA® and MasterCard ®,
Expiry Date: (MM YY) CVC Number: or a 4 digit number on the front of your American Express ® credit card

I authorise the AFP or their agent to process the relevant FOR OFFICE USE ONLY
application amount from the above credit card account.
Payment Confirmation No:
NB: The amount to be deducted is as per the selected
fee specified on Page 1 (Section 1) of this form,
Processed Amount: (AUD) Card Declined
plus a surcharge where payment is by Credit Card.

Page 2 of 5
 AFP NPC FORM-5023

SECTION 8: Purpose of Check (Choose one purpose only from the following list)
If the purpose for your NPC is not listed or you are unsure please call the National Police Check Help Desk on 02 6140 6502 between 8am and 5pm (Australian EST).

ACT Purpose / Employment

Offences recorded in the ACT that will be released
Code Number Please note that the NPC purposes in this section are ONLY for applicants living or working in the Australian Capital
Territory (ACT). If you live outside the ACT and you require a pre-employment/standard disclosure National Police (Spent Convictions Act 2000)
Check, you should contact your local Police service.

Hospital Employment - in the ACT All ACT offences. Other State/Territory offences as legislation permits
Security Licence (Security Guard) - in the ACT All ACT offences. Other State/Territory offences as legislation permits
Aged Care Provider/Worker - in the ACT All ACT offences. Other State/Territory offences as legislation permits
Brothel or Escort Agency Owner/Operator/Interested Party - in the ACT All ACT offences. Other State/Territory offences as legislation permits
Child Care Provider/Worker - in the ACT All ACT offences. Other State/Territory offences as legislation permits
Disabled Care Provider/Worker - in the ACT All ACT offences. Other State/Territory offences as legislation permits
Fire Fighting/Prevention - in the ACT Unspent offences and offences of Arson or Attempted Arson
Firearms Licence/Permit - in the ACT All ACT offences. Other State/Territory offences as legislation permits
Interactive Gambling Licence/Casino Employee - in the ACT All ACT offences. Other State/Territory offences as legislation permits
Prison Officer - in the ACT All ACT offences. Other State/Territory offences as legislation permits
Child/Aged/Disabled Care Provider/Worker - in the ACT All ACT offences. Other State/Territory offences as legislation permits
Working in a School - in the ACT All ACT offences. Other State/Territory offences as legislation permits
Teacher/Teacher’s Aide - in the ACT All ACT offences. Other State/Territory offences as legislation permits
Pre-Employment/Standard Disclosure - in the ACT Unspent offences

Offences recorded in the Commonwealth that will be released

Code Number Commonwealth Employment / Purpose
(Part VIIC Crimes Act 1914)
Aged Care Staff/Volunteers Unspent offences and offences against the person where State/
Territory legislation permits
Aged Care Key Personnel Unspent offences
Australian Securities and Investments Commission Consumer Credit/Financial Unspent offences
Services Licensing Requirements
Care of Intellectually Disabled Persons Unspent offences and offences against the person where State/
Territory legislation permits
Care, Instruction or Supervision of Children Unspent offences as well as any (i) sexual offence, (ii) other offence
against the person if the victim of the offence was under 18 at the time
the offence was committed where State/Territory legislation permits
Civil Aviation Safety Authority ASSC Unspent offences
Immigration Detention Centre Employment Unspent offences and offences involving violence where State/
Territory legislation permits
Immigration/Citizenship – for Supply to the Department of Home Affairs All Commonwealth offences. Other State/Territory offences as
legislation permits
Overseas Visa - Supply to a Country Other than Australia All Commonwealth offences. Other State/Territory offences as
legislation permits
Superannuation Trustee/Custodian/Investment Manager or Responsible Officer of a Unspent offences and offences in respect of dishonest conduct where
Body Corporate that is a Trustee, Investment Manager or Custodian of a State/Territory legislation permits
Superannuation Entity
Care, Instruction or Supervision of Children/Care of Disabled Persons/ Unspent offences as well as any (i) sexual offence, (ii) other offence
Aged Care Staff/Volunteers against the person if the victim of the offence was under 18 at the time
the offence was committed, (iii) offences against the person where
State/Territory legislation permits

Other Commonwealth Purpose ONLY Unspent offences

** If you need a NPC for other than a Commonwealth related purpose, (eg working for a
Commonwealth Department or Agency) you must contact your local Police.

Overseas Employment - General Employment All Commonwealth offences. Other State/Territory offences as
legislation permits
Overseas Employment - Aged/Disabled Care All Commonwealth offences. Other State/Territory offences as
legislation permits
Overseas Employment - Teaching All Commonwealth offences. Other State/Territory offences as
legislation permits
Overseas Employment - Working with Children All Commonwealth offences. Other State/Territory offences as
legislation permits
Overseas Employment - Nursing, Hospital Employment All Commonwealth offences. Other State/Territory offences as
legislation permits

Page 3 of 5
 AFP NPC FORM-5024

SECTION 9: Applicant’s Consent (this section must be completed)

i. I acknowledge I have read all the instructions while completing this application and I am aware exclusions from spent convictions legislation may apply to some categories of NPCs.
ii. The personal information I have provided in this application (including fingerprints if supplied) and all the attachments (if any) relate to me and are correct.
iii. I acknowledge the details contained in this application, including fingerprints where relevant, will be forwarded to the AFP, the Australian Criminal Intelligence Commission, and/or the Police Services of the States or
Territories of the Commonwealth of Australia.
iv. I consent to the AFP and any other Australian police force extracting details of any convictions, findings of guilt or pending court proceedings relating to me, including in relation to any traffic offence, and providing
that information to me or to the Employer/Organisation named in Section 6.
v. I acknowledge the information provided in this application will not be used without my prior consent for any other purpose, unless otherwise authorised by law.
vi. I acknowledge that any information provided in this application or disclosed by the police as a result of the records check may be taken into account by any organisation to whom I present the results of the records check in
assessing my suitability to receive the entitlement.
vii. I acknowledge that only details contained in this application or on attachments signed by me will be checked and that should I subsequently require further names and/or details to be checked then I will be
required to submit a new application and payment.
viii. I understand that it is an offence to provide false or misleading information in this application, or omit to provide information that may result in this application being false or misleading.

Applicant’s Signature: Date:

If you are under 18 years of age (as at the date of the application), please provide consent below from a parent/guardian.

Parent/Guardian’s Name:

Parent/Guardian’s Date:
Signature:

Attachment A: Proof of Identity (this section must be completed)

A minimum of 100 points of identification has to be provided with the application. Please ensure that only photocopies of the original documents are attached.
Note: Documents do not need to be certified unless a translation is being provided or you are supplying a power of attorney

You must supply at least ONE Primary document Required on document Points Points gained
Tick if N = Name, P = photo
Foreign documents must be accompanied by an official translation Worth (applicant to fill)
included A = Address, S = Signature

Foreign Passport (current)

Australian Passport (current or expired last 2 years but not cancelled)
Australian Citizenship Certificate
Full Birth certificate (not extract)
Certificate of Identity issued by the Australian Government to refugees and non Australian citizens for
entry to Australia
Australian Driver License/Learner’s Permit
Current (Australian) Tertiary Student Identification Card
Photo identification card issued for Australian regulatory purposes (e.g. Aviation/Maritime Security
identification, security industry etc.)
Government employee ID (Australian Federal/State/Territory)
Defense Force Identity Card (w/ photo or signature)

Department of Veterans Affairs (DVA) card

Centrelink card (with reference number)
Birth Certificate Extract
Birth card (NSW BDM only)

Medicare card
Credit card or account card
Australian Marriage certificate (Registry issue only)
Decree Nisi / Decree Absolute (Registry issue only)
Change of name certificate (Registry issue only)
Bank statement
Property lease agreement - current address
Taxation assessment notice
Australian Mortgage Documents
Rating Authority - eg Land Rates
Utility Bill - electricity, gas, telephone (less than 12 months old)
Reference from Indigenous Organisation
Documents issued outside Australia (equivalent to Australian documents). Must have official
translation attached

Page 4 of 5
 AFP NPC FORM-5025

Submission Checklist
Prior to submitting your application, please complete the checklist below to ensure your request can be processed in a timely manner. Failure to complete or supply any
part of the application may result in it being returned prior to processing.

All required details in Sections 1 to 9 are complete.

I can be reached during business hours on the phone number I have provided in section 3.
I have attached photocopies of my identification, for documents selected in attachment A above.
I have provided my credit card details for electronic payment or I will attach a cheque or money order payable to the AFP for the current fee.
(optional) If a fingerprint check is required, I have provided my fingerprints and if relevant, a copy of the receipt for payment.

Once all the above steps have been completed, attach your photocopied identification documents and payment to the application form and post to:
Australian Federal Police
Criminal Records
Locked Bag 8550
CANBERRA CITY ACT 2601

Page 5 of 5
 AFP NPC FORM-5026

Attachment B: Other names you have used (use only if required)

Former Name Also known as Date of Birth: (DD MM YYYY)

Family Name / Surname :

First Name / Given Name:

Other Given Names:

Former Name Also known as Date of Birth: (DD MM YYYY)

Family Name / Surname :

First Name / Given Name:

Other Given Names:

Former Name Also known as Date of Birth: (DD MM YYYY)

Family Name / Surname :

First Name / Given Name:

Other Given Names:

Attachment C: Previous Residential Address (use only if required - must not be a PO Box or Business Address)

Unit No / Street No /
Street Name:

Suburb / Town / Locality:

Postcode: State:

Country:

Date you started living at this address: (DD MM YYYY)

Unit No / Street No /
Street Name:

Suburb / Town / Locality:

Postcode: State:

Country:

Date you started living at this address: (DD MM YYYY)

Unit No / Street No /
Street Name:

Suburb / Town / Locality:

Postcode: State:

Country:

Date you started living at this address: (DD MM YYYY)

Optional Attachment