Reference C ode: Office use only

Date received:
5J9LS4F

Licence number issued:

Victorian Private Security Individual Operator Licence Application

Part 1 - Personal Information

Current Name
First Given Name
Arman

Second Given Name Third Given Name

Family Name *
Darrehaghaedi

Preferred Name

Sex *
Male Female

Date of Birth
Day * Month * Year *
8 Nov 1998

Town of Birth * C ountry of Birth *

dubai Australia

Previous Name(s)
Have you ever changed your name in an official capacity? *

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 Yes No

Have you ever been known by another name (not including official name changes)? *
Yes No

Contact Details
Please enter your phone number *
Home Phone Mobile Number
(0_) _____ ____ 0470 134 403

Business Phone

Driver's Licence Number State *

036314129 Victoria

By providing Driver Licence information, I hereby authorise Victoria Police to obtain from the Roads C orporation (Vic
Roads) information that relates to my identity that is kept by the Roads C orporation (Vic Roads).

Medicare Number
6257422224

Passport Number * Passport C ountry of Nationality *

0079547840254 Australia

Email Address
Email Address *
armantrj@yahoo.com

Residential Address
Full Address
45 JOHN EDGC UMBE WAY, ENDEAVOUR HILLS VIC 3802

Is your Postal Address the same as your Residential Address? *

Yes No

Prefill
Are your contact details pre-filled correctly? *
Yes No

Part 2 - Type of Application

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Private Security Activities and Sub-Activities
What Security Activities are you applying for? *
Please Note: If the security activity of Armed/Unarmed Guard is checked the activity of Unarmed Guard is not
selectable.

Security Guard

You have selected Security Guard, you must select the sub-activity/activities you require *

Unarmed Guard Monitoring Centre Operator

Control Room Operator Guard with a dog
Armed / Unarmed Guard Cash in Transit

Crowd Controller

Investigator

Bodyguard

Private Security Trainer

Fingerprints
Have you had your fingerprints taken? *
Yes No

Date of Issue of National Police Record C heck C ertificate

Day * Month * Year *
3 Apr 2019

Part 3 - Previous History

Criminal History
Have you ever been convicted of any offence in Australia or Overseas? (not traffic charges) *
Yes No

Have you ever been found guilty of any offence without a conviction being recorded? (not traffic charges) *
Yes No

Do you have any charges pending against you? (not traffic charges) *
Yes No

Have you ever received a diversion at court? (not traffic matter) *

Yes No

Other Private Security Licence History

3 / 12
Have you ever been the subject of any refusal, cancellation, suspension or prohibition of a Private Security
Licence/Registration in Australia or Overseas? *
Yes No

Other Information
Have you served as a member of the Australian Police Force in the last 10 years? *
Yes No

Is there any other relevant information that you believe should be considered by the Licensing & Regulation Division
when assessing your application? *
Yes No

Part 4 - Medical History

Medical History
Do you currently have any medical or psychiatric conditions or impairments that may directly impact your ability to hold a
Private Security Licence for the reasons or activities being applied for? *
Yes No

In the past 5 years have you been treated for:

Mental health conditions including, but not limited to, depression or stress? *
Yes No

Alcohol or drug related problems? *

Yes No

A physical disability or any other medical condition (e.g. neurological, stroke or brain injury) which could impact your
ability to hold a licence, registration or approval? *
Yes No

If you answered 'Yes' to any of the above questions you must obtain a medical report. The medical report
must:
• Be legible and written on the letterhead of the relevant registered medical practitioner who is, or has been treating
you or is familiar with your conditions;
• Outline the medical conditions for which you are being, or have been, treated;
• State whether your current or past medical conditions may prevent you from being a fit and proper person to hold
a Private Security Licence for the reasons or activities being applied for; and
• Be signed and dated by the relevant registered medical practitioner.
Please note that the medical report must be current.

Part 5 - Employment Details

Employment details
Do you have employment arranged in the security industry? *
Yes No

4 / 12
Part 6 - Suitability Reference
Suitability Reference
At the completion of this form, you are required to complete the two written suitability reference forms. Referees must be
a class of person as listed on the Victoria Police Suitability Reference Form (see website)
Your referees must not be related to you by birth or marriage and must have known you while you have lived in
Australia, for 12 months or more.
Your suitability references must:
• Be no more than 12 months old;
• C ontain the full name, address, contact details and authority type of the referee; and
• Indicate that you are of suitable character to hold a Private Security Licence with the activities being applied for.
See the attached Suitability Reference Forms for more information.
Extra Suitability Reference Forms can be downloaded from our website.

5 / 12
Part 7 - Identification Reference
Section A - Australian Residency
Are you an Australian C itizen or permanent resident? *
Yes No

Do you have work rights that permit you to work in the security industry? *
Yes No

Please enter your Visa details

Visa Type * Details *

Other Visa safe haven enterprise class XE

Visa Expiry Date

Day * Month * Year *
26 May 2022

Section B - Identification Requirements

Do you hold a Victorian Firearm Licence, Security Licence, Security Registration, or a C hief C ommissioner of Police
Weapon Approval that is current or has expired in the last 6 months? *
Yes No

Have you previously held a Victorian or Interstate Private Security Licence/Registration? *

Yes No

Identification Documents
As you do not hold a current Victorian Firearms Licence or a current Victorian C C P Weapons Approval, you must provide
a total of 100 points in identification documents. These documents must comprise of one primary identification document
(normally your evidence of Australian residency or authority to work) and multiple secondary identification documents.
One of your secondary identification documents must include your current residential address.
• All of these documents must be photocopies of the original certified by an acceptable Identification Referee
Please nominate which identification documents you will provide:

Primary Identification *

Diplomatic documents

Secondary Identification *

Any licence issued under Australian law (i.e. Driver Licence) including photograph and/or signature
Licence Number * State *
036314129 Victoria

Medicare Card
Medicare Number *

6 / 12
 6257422224

Credit Card statement

Public Service ID including photograph and/or signature

Social Security Card including photograph and/or signature

Identification Card issued by a Tertiary education institution including photograph and/or signature

Authorised Deposit Taking Institution (customer of at least 12 months) e.g. Bank

Mortgage documents

Land Titles Office Document

Letter from Employer (within the last 2 years) confirming name and address

Municipal Council Rates Notice

Telephone Account

Electoral Roll compiled by the Australian Electoral Office

Records of public utility (i.e. water, gas, electricity)

Statement from a primary, secondary or tertiary institution that you attended in the last 10 years
confirming your name and address

Records from a professional or trade association (union or trade/professional body) confirming your
name and address
Total points of selected documents: 160

7 / 12
Section C - Declaration by Referee
This declaration must be made by an "Acceptable Identification Referee" as listed in the Instruction Pages.
The Identification Referee must have known the applicant for at least 12 months. The applicant must sign this declaration
in the presence of the Identification Referee.
The same referee must also certify the copies of your identification documents that you nominated above.
Referee to complete:

I, the Referee,

Of

declare that I have

known

for a period of years and months.

Type of Acceptable Referee.

(Refer to instruction pages for a list of acceptable referees) Referee Telephone C ontact Details

Referee to complete:
I, the Referee, also certify that the above details are true and correct, the applicant’s signature was completed in my
presence, and the identification documents I have signed are a true copy of the original.

Referee's Signature

Print Name Date

/ /

Applicant to sign and date in presence of referee:

I, the applicant, am providing the following certified identification documents:
• Diplomatic Documents
• Driver's Licence
• Medicare
• C redit C ard Statement

Applicant's Signature

8 / 12
Print Name Date
/ /

9 / 12
Part 8 - Acknowledgement
Acknowledgement
You must sign and date again to confirm that all the information you have supplied is true and correct:

I acknowledge that the particulars in this application and any attachments are true and correct and I
make this acknowledgement knowing that it is an offence against Section 135 of the Private Security
Act 2004 to wilfully supply details which are incorrect or omit to furnish particulars. *

I acknowledge that I will be required to submit a paper-based copy of this application *

Applicant's Signature

Print Name Date

/ /

Privacy Statement: The personal and health information requested is being collected and used by Victoria Police for the
purposes of assessment of an application for a licence, registration, permit or approval. It will be used in accordance with
relevant legislation, including the Firearms Act 1996, Private Security Act 2004, Control of Weapons Act 1990, Health
Records Act 2001 and the Privacy and Data Protection Act 2014. The information may be disclosed to employers,
approved bodies and other statutory authorities for the purposes of law enforcement and the administration of justice. To
gain access to personal and health information held by Victoria Police, you must apply in writing to the Freedom of
Information Division of Victoria Police, at www.police.vic.gov.au

10 / 12
 Instruction Pages - Please remove Application Summary before submitting your application

Application Summary
How do I complete my application?
Please see Instruction Pages for further advice with completing and lodging your application.

• You have submitted the electronic version of your application; you must now complete the rest of this
application in hard-copy.
• Please refer to the Instruction Pages for more information on how to finalise and submit your application.
• Prepare all supporting documents listed in the below Application checklist.
• If required, you must complete Section C - Declaration by Referee. This section must be signed by an acceptable
referee and yourself.
• You must sign and date the Acknowledgement section.

Application checklist
Part 1 - Type of Application

You must provide a certified/attested copy of your “statement of results” document/certificate (dated within the past
12 months) for all activities applied for, including details of units completed:
◦ C rowd C ontroller
◦ Security Guard
◦ Unarmed Guard
Fingerprint requirements:

A certified copy of your National Police Records C heck C ertificate

Part 6 - Suitability Requirements

2 Suitability References completed by 2 different acceptable referees. Please refer to the ‘Suitability Reference’ form
(attached) and follow the instructions provided.

Part 7 - Identification Reference (please ensure the referee who completes Identification Reference
section has certified your identity documents)
As you answered 'No' to being an Australian Citizen or Permanent Resident of Australia:
You must provide certified evidence of your Australian Residency as part of the identification requirements. You are
required to provide your:

C ertified copy of your passport, your visa and your work entitlement details. Your visa must be valid for at least
12 months for your application to be considered.

C ertified copy of your criminal history check as provided to the Department of Immigration and Border Protection
(this is not required if you are a permanent resident or Australian citizen)

If you are from New Zealand (NZ), you are required to supply a copy of your NZ passport and a copy of the
visa page clearly showing the Immigration Australia stamp with the date of arrival in Australia certified by
an acceptable referee.
Section B - Identification Requirements
As you do NOT hold a current Victorian Firearms Licence or CCP Weapons Approval:

100 points of identification certified by an acceptable identification referee

Section C - Declaration by Referee

11 / 12
As you do NOT hold a current Victorian Firearms Licence or CCP Weapons Approval:

The Declaration by Referee completed by an acceptable identification referee.

Part 8 - Acknowledgement

You must sign and date the Acknowledgement section, even if you have also signed the declaration in Identification
Reference section.

How do I submit my application?

• Do not send original identification documents, cash, cheques or money orders
• Attach all supporting documents securely to the back of the application form and forward to:
Licensing & Regulation Division
GPO Box 2807
Melbourne VIC 3001

How do I make payment?

• Do not send any payment with your application. A "Payment Notice" will be sent to you upon receipt of your
application. Your application will not be assessed until you have made payment.
• The total fee includes a non-refundable administration fee. If your application is abandoned, withdrawn or refused,
you will receive a refund for the licence fee, but not for the administration fee. All application fees are GST exempt.
• For a schedule of fees, contact the Licensing & Regulation Division or visit our website.

How do I track the progress of my application after submission?

After you have submitted your application and supporting documents in hard-copy, you can see progress of your
application through your Victoria Police eServices account (can be also accessed via Victoria Police website).
Applications are normally processed within 28 calendar days of receipt
The following factors can increase the time it takes to process an application:
• A person has adverse history;
• An application is incomplete;
• C omplexity of the application.
Licensing & Regulation Division are unable to respond to enquiries relating to the processing status of applications
received within the last 28 days.
If 28 calendar days have elapsed and you require an update on the status of your application, please contact us via email
with your full name, date of birth, type of application, date sent and licence number (if available).

12 / 12
 VP Form 1080

Please remove Instruction Pages before submitting your application

Instruction Pages
Individual Operator Private Security Licence Application

Required Documentation

Please refer to your Application Checklist to confirm the required documentation for your application.

Requirement to be fingerprinted

You must have your fingerprints taken and supply a certified copy of your National Police Records Check Certificate with this
application. Call 1300 881 596 between 8am and 4pm Monday to Friday to make an appointment (for both metropolitan and country
applicants.) Your application will not be approved until you submit your National Police Records Check Certificate.

Suitability Reference

• Your application must include 2 suitability references that state you are of suitable character to hold a Private Security Licence
for the activities being applied for.

• Suitability references must be provided in written format on the Victoria Police Suitability Reference Form. These are available
from the Licensing & Regulation Division website or your Registered Training Organisation. See attached Suitability
Reference Forms for more information.

• For a list of referees who can provide you with a Suitability Reference please see the Victoria Police Suitability Reference
Form.

• Suitability references must:

Be dated and no more than 12 months old.
Contain the full name, address, contact details, authority type and signature of your referee.
Contain evidence of the referee’s authority such as a professional association or regulatory body membership number.

• Please note that your referee must know you well enough to vouch for your character. For example, a reference from your
accountant might not be accepted if you only see him/her once a year for tax purposes.

• Suitability references sourced from overseas authorities will not be accepted.

How do I certify documents?

• Photocopies of original documents must be certified by an acceptable referee as a “true copy of the original”. The original
document must be sighted by the acceptable referee.

• All your identification documents must be certified by the same identification referee who signs Declaration of Referee
section of the application form.

• You must sign and date Declaration of Referee section of the application form in the presence of your identification referee.

Instructions: | 1
Identification Reference continued – List of Acceptable Referees

The Referee must have known you for at least 12 months.

A member of A member of a municipal, city, town, district An employee of a financial institution who is
or shire council of a State or Territory. authorised by the financial institution to open
• the Chartered Accountants Australia, accounts with the institution.
and New Zealand.
• the Australian Society of Accountants, or
• the Institute of Public Accountants.
An agent of a financial institution who is A full time employee of An employee of a bank carrying on a
authorised by the financial institution to open • a financial institution; or business outside Australia
accounts with the institution. • a corporation that is a registered • that does not have an authority under
corporation within the meaning of the section 9 of the Banking Act 1959; and
Financial Sector (Collection of Data) • that is engaged in a transaction with a
Act 2001; cash dealer;
who has been employed continuously for at who is authorised by the bank to open
least 5 years by one or more financial accounts with the bank.
bodies.
A full-time employee of a company carrying A legal practitioner of a Federal, State or A registrar, clerk, sheriff or bailiff of a
on insurance business who has been Territory Court. Federal, State or Territory Court
employed continuously for at least 5 years
by one or more companies of that type.
An officer within the meaning of the Defence An individual registered or licensed as An individual who is employed and
Act 1903. • a dentist, registered as a nurse under the law of a
• a medical practitioner, State or Territory providing for that
• a pharmacist, or registration.
• a veterinary surgeon,
under a law of a State or Territory providing
for that registration or licensing.
A diplomatic or consular officer of an A holder of an office established by a law of A judge or master of a Federal, State or
Australian Embassy, High Commission or the Commonwealth, a State or Territory in Territory Court.
Consulate, in Australia or overseas. respect of which annual salary is payable.
A stipendiary magistrate of the A justice of the peace of a State or Territory. A member of the Federal Parliament or a
Commonwealth or of a State or Territory. State Parliament.
A member of the Legislative Assembly of the A minister of religion who is registered as a A notary public.
Australian Capital Territory, the Northern marriage celebrant.
Territory or Norfolk Island.
A member of the Australian Federal Police, A member of the Australian Federal Police, A manager of a post office.
or of the police force of a State or Territory, or of the police of a State or Territory, of or
who in the normal course of his or her above the rank of sergeant.
duties, is in charge of a police station.
An individual employed as an officer or An individual employed as a full-time teacher An individual who, in relation to an Aboriginal
employee by one or more of the following: or as a principal at one or more of the community
• the Commonwealth, a State or Territory; following educational institutions: • is recognised by the members of the
• an authority of the Commonwealth, a • a primary or secondary school forming community to be a community elder; or
State or Territory; or part of the education system in a State • if there is an elected Aboriginal council
• a local government body of a State or or Territory; or that represents the community – is an
Territory; • an institution listed in section 4 or elected member of the council.
who has been so employed continuously for paragraphs 34(4)(b)-(j) (inclusive) of
a period of at least 5 years, whether or not the Higher Education Funding Act
the individual was employed for part of that 1988;
period as an officer and for part as an who has been so employed continuously for
employee. a period of at least 5 years.
An individual who is an agent of a totalisator A Commissioner for oaths of a State or An individual who is registered as a tax
agency board if Territory. agent under part VIIA of the Income Tax
• the individual conducts an agency of Assessment Act 1936.
the totalisator agency board at
particular premises; and
• the agency is not ancillary to any other
business conducted at those premises.
A member of the Chartered Institute of A member or fellow of the Association of A member of the Institution of Engineers
Company Secretaries in Australia Limited. Taxation and Management Accountants. Australia, other than a member with the
grade of student.
A fellow member of the National Tax and
Accountants’ Association Limited.

You must ask the Acceptable Referee to

a) sign the copy of the identification documents that you are providing in order to indicate that it is a true copy of the
original as demonstrated on the previous page; and
b) complete all required parts of the “Declaration by Referee” section of the application form as instructed on the
form. Please note that this includes witnessing you (the applicant) signing the application in their presence.

Make sure you include the signed identification documents with your application by stapling them to the back of the application.

Instructions: | 2
 VP Form 1299

SUITABILITY REFERENCE
PART 1: ADVICE TO THE REFEREE (to be read prior to completing this reference)
The purpose of this written reference is for you to attest that, in your opinion, the applicant is of a suitable character to
hold a private security licence/registration in Victoria. You are not obliged to provide this suitability reference.
To provide this reference you must—
• Belong to a prescribed class of persons in accordance with the Private Security Regulations 2016. Refer to the
reverse side of this page for information on the prescribed classes of persons.
• Have known the applicant for at least 12 months in Australia.
• Not be related to the applicant by birth or marriage.
If you cannot attest to all of the above do not complete this suitability reference.
Please complete this form in BLOCK LETTERS.
PART 2: REFEREE TO COMPLETE THE FOLLOWING STATEMENT OF SUITABILITY
I (referee’s name) _______________________________________________, make the following written reference
in relation to the suitability of (applicant’s name) _______________________________________________ to
work in the private security industry.

• I have known the applicant for a period of _________ year(s) _________ month(s) and I am not related to
them by birth or marriage.
• What is your relationship to the applicant? Please tick the relevant box, and provide specific detail.

Professional. Please specify:

Personal. Please specify:

Professional and personal. Please specify:

• What is the frequency of your contact with the applicant? Please tick the relevant box
Daily Weekly Monthly Quarterly – At least every 3 months

Other – Please specify:

• Prior to arranging this declaration, what was the date of your last contact or interaction with the applicant?
___________________________________________________________________________________________
• What was the reason for the contact or interaction?
___________________________________________________________________________________________
• I have observed the following skills and characteristics (traits) that would make the applicant suitable for
work in the private security industry:
Your response must relate to the applicant’s ability to interact effectively with people in a variety of settings,
general demeanour, whether they are law abiding, can communicate effectively using the English language and
any other consideration that is relevant to their fitness for work in the industry. If you require additional space for
your comments, please provide a signed and dated attachment.

Please Turn Over

Revised: 03/19
 VP Form 1299

PART 3: REFEREE TO INDICATE PRESCRIBED CLASS

Prescribed classes of persons in Australia are those authorised under section 30 of the Oaths and Affirmations Act
2018 and regulation 49 of the Private Security Regulations 2016.
Note: The Licensing & Regulation Division will seek verification that you belong to a prescribed class by contacting
the relevant authority to which you prescribe.
Please tick the appropriate class to indicate which prescribed class you belong to:
A medical practitioner registered under the Health The manager of an authorised deposit-taking
Practitioner Regulation National Law. institution.
A pharmacist registered under the Health A principal within the meaning of the Education and
Practitioner Regulation National Law. Training Reform Act 2006.
A dentist registered under the Health Practitioner A registered veterinary practitioner within the
Regulation National Law, who also holds dental meaning of the Veterinary Practice Act 1997.
practitioner registration. A justice of the peace.
A prescribed member of a prescribed accounting A nurse registered under the Health Practitioner
body or association – Regulation National Law.
• A member of CPA Australia Ltd who holds the A registered teacher within the meaning of the
designation of a Certified Practising Accountant; Education and Training Reform Act 2006 or a
• A Fellow of CPA Australia Ltd. corresponding law of another State or Territory.
• A member of the Institute of Public Accountants
An Officer of the Australian Defence Force within
who holds a current practising certificate.
the meaning of the Defence Act 1903 (Cth).
• A member of the Institute of Chartered
Accountants in Australia. A holder of a Victorian private security business
• A member of Chartered Accountants Australia licence (or if the holder is a body corporate, the
and New Zealand who resides in Australia. nominated person) who for at least 5 years
continuously held that licence or was the nominated
A minister of religion authorised to celebrate person in relation to the licence.
marriages.
Another prescribed class (not listed above) –
An Australian lawyer or clerk to an Australian please specify:
lawyer.
_________________________________________.
Note: The above prescribed classes of persons are seen to be those most commonly known to the majority of
people. For a full list of the prescribed classes, go to www.police.vic.gov.au/privatesecurity and download the
Prescribed Classes of Persons to Provide Suitability Reference information sheet.
Due to conflict of interest, members of Victoria Police are unable to provide suitability reference.

State here your official identification reference as known by the relevant authority, including any
authorised/registration number and/or stamp:

PART 4: REFEREE TO COMPLETE THE FOLLOWING DECLARATION

I make this reference as I belong to a prescribed class of persons in Australia.
I acknowledge that the particulars in this suitability reference are true and correct and I make this acknowledgement
knowing it is an offence under section 135 of the Private Security Act 2004 to wilfully supply details which are false or
misleading or omit to furnish particulars.
In signing this declaration I am aware that I may be called upon to attest to this statement in a court of law.

Referee’s Signature: ____________________________________________________ Date: _________ /_________/_________________

Referee’s Printed Name: ___________________________________________________________________________________________

Work Address: _____________________________________________________________________________________________________

Phone: (H) ________________________________ (W) ________________________________ (M) ________________________________

E-mail Address: ___________________________________________________________________________________________________

Privacy Statement: The personal and health information requested is being collected and used by Victoria Police for the purposes of assessment
of an application for a licence, registration, permit or approval. It will be used in accordance with relevant legislation, including the Firearms Act
1996, Private Security Act 2004, Control of Weapons Act 1990, Health Records Act 2001 and the Privacy and Data Protection Act 2014. The
information may be disclosed to employers, approved bodies and other statutory authorities for the purposes of law enforcement and the
administration of justice. To gain access to personal and health information held by Victoria Police, you must apply in writing to the Freedom of
Information Division of Victoria Police, at www.police.vic.gov.au.

Revised: 03/19
 VP Form 1299

SUITABILITY REFERENCE
PART 1: ADVICE TO THE REFEREE (to be read prior to completing this reference)
The purpose of this written reference is for you to attest that, in your opinion, the applicant is of a suitable character to
hold a private security licence/registration in Victoria. You are not obliged to provide this suitability reference.
To provide this reference you must—
• Belong to a prescribed class of persons in accordance with the Private Security Regulations 2016. Refer to the
reverse side of this page for information on the prescribed classes of persons.
• Have known the applicant for at least 12 months in Australia.
• Not be related to the applicant by birth or marriage.
If you cannot attest to all of the above do not complete this suitability reference.
Please complete this form in BLOCK LETTERS.
PART 2: REFEREE TO COMPLETE THE FOLLOWING STATEMENT OF SUITABILITY
I (referee’s name) _______________________________________________, make the following written reference
in relation to the suitability of (applicant’s name) _______________________________________________ to
work in the private security industry.

• I have known the applicant for a period of _________ year(s) _________ month(s) and I am not related to
them by birth or marriage.
• What is your relationship to the applicant? Please tick the relevant box, and provide specific detail.

Professional. Please specify:

Personal. Please specify:

Professional and personal. Please specify:

• What is the frequency of your contact with the applicant? Please tick the relevant box
Daily Weekly Monthly Quarterly – At least every 3 months

Other – Please specify:

• Prior to arranging this declaration, what was the date of your last contact or interaction with the applicant?
___________________________________________________________________________________________
• What was the reason for the contact or interaction?
___________________________________________________________________________________________
• I have observed the following skills and characteristics (traits) that would make the applicant suitable for
work in the private security industry:
Your response must relate to the applicant’s ability to interact effectively with people in a variety of settings,
general demeanour, whether they are law abiding, can communicate effectively using the English language and
any other consideration that is relevant to their fitness for work in the industry. If you require additional space for
your comments, please provide a signed and dated attachment.

Please Turn Over

Revised: 03/19
 VP Form 1299

PART 3: REFEREE TO INDICATE PRESCRIBED CLASS

Prescribed classes of persons in Australia are those authorised under section 30 of the Oaths and Affirmations Act
2018 and regulation 49 of the Private Security Regulations 2016.
Note: The Licensing & Regulation Division will seek verification that you belong to a prescribed class by contacting
the relevant authority to which you prescribe.
Please tick the appropriate class to indicate which prescribed class you belong to:
A medical practitioner registered under the Health The manager of an authorised deposit-taking
Practitioner Regulation National Law. institution.
A pharmacist registered under the Health A principal within the meaning of the Education and
Practitioner Regulation National Law. Training Reform Act 2006.
A dentist registered under the Health Practitioner A registered veterinary practitioner within the
Regulation National Law, who also holds dental meaning of the Veterinary Practice Act 1997.
practitioner registration. A justice of the peace.
A prescribed member of a prescribed accounting A nurse registered under the Health Practitioner
body or association – Regulation National Law.
• A member of CPA Australia Ltd who holds the A registered teacher within the meaning of the
designation of a Certified Practising Accountant; Education and Training Reform Act 2006 or a
• A Fellow of CPA Australia Ltd. corresponding law of another State or Territory.
• A member of the Institute of Public Accountants
An Officer of the Australian Defence Force within
who holds a current practising certificate.
the meaning of the Defence Act 1903 (Cth).
• A member of the Institute of Chartered
Accountants in Australia. A holder of a Victorian private security business
• A member of Chartered Accountants Australia licence (or if the holder is a body corporate, the
and New Zealand who resides in Australia. nominated person) who for at least 5 years
continuously held that licence or was the nominated
A minister of religion authorised to celebrate person in relation to the licence.
marriages.
Another prescribed class (not listed above) –
An Australian lawyer or clerk to an Australian please specify:
lawyer.
_________________________________________.
Note: The above prescribed classes of persons are seen to be those most commonly known to the majority of
people. For a full list of the prescribed classes, go to www.police.vic.gov.au/privatesecurity and download the
Prescribed Classes of Persons to Provide Suitability Reference information sheet.
Due to conflict of interest, members of Victoria Police are unable to provide suitability reference.

State here your official identification reference as known by the relevant authority, including any
authorised/registration number and/or stamp:

PART 4: REFEREE TO COMPLETE THE FOLLOWING DECLARATION

I make this reference as I belong to a prescribed class of persons in Australia.
I acknowledge that the particulars in this suitability reference are true and correct and I make this acknowledgement
knowing it is an offence under section 135 of the Private Security Act 2004 to wilfully supply details which are false or
misleading or omit to furnish particulars.
In signing this declaration I am aware that I may be called upon to attest to this statement in a court of law.

Referee’s Signature: ____________________________________________________ Date: _________ /_________/_________________

Referee’s Printed Name: ___________________________________________________________________________________________

Work Address: _____________________________________________________________________________________________________

Phone: (H) ________________________________ (W) ________________________________ (M) ________________________________

E-mail Address: ___________________________________________________________________________________________________

Privacy Statement: The personal and health information requested is being collected and used by Victoria Police for the purposes of assessment
of an application for a licence, registration, permit or approval. It will be used in accordance with relevant legislation, including the Firearms Act
1996, Private Security Act 2004, Control of Weapons Act 1990, Health Records Act 2001 and the Privacy and Data Protection Act 2014. The
information may be disclosed to employers, approved bodies and other statutory authorities for the purposes of law enforcement and the
administration of justice. To gain access to personal and health information held by Victoria Police, you must apply in writing to the Freedom of
Information Division of Victoria Police, at www.police.vic.gov.au.

Revised: 03/19