*2698 Z 0675627 JIVO 150515 35
National Police Certificate Application Form
Supplementary Application to Spend Eligible WA Convictions
Handwritten changes made to this form will not be accepted. If information needs to be changed, a new application form will need to be completed and printed.
Do not sign the form until you lodge your application as your signature must be witnessed by an Australia Post Officer (excluding guardian signature).
APPLICATION SUMMARY
How to Lodge your Application
You must lodge your application in person at an Australian Post outlet. To locate your nearest authorised outlet ring 13 13 18 or visit http://auspost.com.au/
pol/app/locate. When lodging your application at a participating Australia Post outlet, you must bring:
- Your original printed application summary - photocopies will not be accepted
- Proof of your signature, current address and date of birth.
- If you have had a change of name, documentation to prove this is required.
- The required fee - payment must be by EFTPOS, Mastercard, Visa or cash - cheques will not be accepted. If you are unsure of current fees that apply,
please contact WA Police Information Release Centre via http://www.police.wa.gov.au/Ourservices/InformationAccess/InformationAccessFees/tabid/2026/
Default.aspx
Proof of Identification Documents
It is a requirement when applying for a NPC that you provide proof of your identity to Australia Post when you lodge your application. An Australia Post
officer will ask you to provide documents of identity that add up to at least 100 points. The combination of documents supplied should, as a minimum, show
evidence of your full name and date of birth. All documents must be original. Proof of identity documents must be from the list below:
PRIMARY DOCUMENTS (70 Points) SECONDARY DOCUMENTS (40 Points) SECONDARY DOCUMENTS (25 Points)
One Primary Document Required or at least If more than one document is supplied, the
one Secondary Document with Photograph second will carry 25 Points - Proof of age Card (issued by DPI)
- Full Birth Certificate or Birth Card issued by the - Australian Photo Drivers Licence - Medicare Card
Registrar of Births, Deaths and Marriages - Australian Photo Firearm Licence - Council Rates Notice
- Australian Passport (current or expired within - State or Federal Government Employee Photo - Property Lease/Rental Agreement
the last two years, but not cancelled) Identity - Property Insurance Papers
- Australian Citizenship Certificate - Tertiary Education Institution Photo Identity - Motor Vehicle Registration or Insurance
- International Passport (current, NOT expired or - Australian Learner's Permit Documents
cancelled) - Department of Veterans Affairs Card - Professional or Trade Association Card
- Centrelink or Social Security Card - Credit/Account Card or Bank Statement/Passbook
Details of Applicant
Family Name/Surname: Volmer Date of Birth: 22 Jul 1961
Given Name/s: Jim Bernardus Town of Birth: Not Required
Applicant's Address: 91 Glenisla Road Country of Birth: Netherlands
Bickley WA 6076 Telephone Number: 0409120980
Declaration
I certify that I am the applicant named in this form and all the details herein provided by me are true and correct. I have read and understood the contents of this form and advisory
notes. I consent to a check of the records of all Australian police jurisdictions and to the release of any other convictions, findings of guilt, either with or without conviction, any
matters still outstanding against me and any other matters deemed to be relevant which are recorded against my name.
Signature of Applicant* Signature of Parent/Guardian
Please Sign
within the box
and use black ink
Date signed* Signature of parent or guardian is required for applicants
D D M M Y Y Y Y under 15 years of age on the day of lodgement
Australia Post Use Only
I declare that the Photo ID sighted is a true likeness of the applicant. I have sighted and confirmed the Proof of Identity against original documentation.
Work Centre Code* Date* Verifier's Signature*
D D M M Y Y Y Y
Application Page 1 of 1
