Afp Check Form Reference

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  • Topic: Given name, Personal name, Passport
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  • Published : May 4, 2013
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AFP NPC FORM-5021

Payment Consent

Ref No:
Notes:

NATIONAL POLICE CHECK (NPC) APPLICATION FORM

Proof of IDs Mandatory Details Fingerprints (attached) Fingerprints (paid)

Website: www.afp.gov.au Telephone: 02 6102 6102 Fax: 1300 549 456 Email: AFP-NationalPoliceChecks@converga.com.au ABN: 17 864 931 143 Office Hours: 8am to 5pm, Monday to Friday (except A.C.T 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).

SECTION 1: Type of check required
Name Check Only (Fee: $42)

(this section must be completed - select only one)

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.

Fingerprint Type: (select only one) Police Station:

Ink

Livescan Officer’s Name & No:

Date Taken: Ref No:

(DD MM YYYY)

SECTION 3: Details of Applicant
Family Name / Surname : First Name / Given Name: Other Given Names: Date of Birth: Were you born in Australia? Yes No Suburb / Town of Birth: Country of Birth: (DD MM YYYY) Male Female

(this section must be completed)

State:

Daytime Contact Number: Email Address (optional): Australian Driver’s Licence No: Issuing State:

SECTION 4: Other names you have used
Former Name Also known as Date of Birth:

(including former, maiden name/s etc)
(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 4

AFP NPC FORM-5022

SECTION 5: Current & Previous Residential Addresses
Current Residential Address (must not be a PO Box or Business Address) Unit No / Street No / Street Name: Suburb / Town / Locality: Postcode: Country: Date you started living at this address: State:

(this section must be completed)

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

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: Country: State:

SECTION 7: Payment Details
Credit Card/Debit Card (please complete card details below) Cardholder’s Name: Credit Card Number: Expiry Date: (MM YY) CVC Number: FOR OFFICE USE ONLY

(this section must be completed)
Bank Cheque Money Order

Mastercard
(Surcharge: 0.528%

Visa
0.528%

Amex
1.595%)

I authorise the AFP or their agent to process the relevant application amount from the above credit card account. NB: The amount to be deducted is as per...
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