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Interim Certificate Amendment: Use This Form If

This document is an application form for amending incorrect details on an interim certificate issued by the Office of Liquor, Gaming and Racing in New South Wales, Australia. It explains that the form should be used if the applicant's details are incorrect on their interim certificate and they have not yet applied for their photo ID competency card. It provides instructions on completing and submitting the form, which includes filling in the applicant's incorrect details according to the interim certificate, providing their correct details to match their 100 points of ID, and obtaining details and signatures from their approved training provider and themselves.

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450 views2 pages

Interim Certificate Amendment: Use This Form If

This document is an application form for amending incorrect details on an interim certificate issued by the Office of Liquor, Gaming and Racing in New South Wales, Australia. It explains that the form should be used if the applicant's details are incorrect on their interim certificate and they have not yet applied for their photo ID competency card. It provides instructions on completing and submitting the form, which includes filling in the applicant's incorrect details according to the interim certificate, providing their correct details to match their 100 points of ID, and obtaining details and signatures from their approved training provider and themselves.

Uploaded by

dimuthh7441
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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RSA/RCG

Application form

Interim certificate amendment


Use this form if:
The details on your interim certificate appear incorrectly and you
have not yet applied at Australia Post for your competency card.
Note: Information on your interim certificate has been entered
by your training provider. If there are errors on your certificate,
please complete this form.
DO NOT use this form if you already have your photo ID
competency card and need to change your name as it appears
on the card. To change your name on the card you must use the
Replacement Card form, CC0500.
1. Complete all questions. If information is missing, it will delay
processing time as we will have to contact you to obtain
the information.

CC0300

OFFICE USE ONLY


By (circle): mail | OTC | fax | email

Date lodged
Request number
Finalised by
Date finalised

2. If you need help in completing this application, call (02) 9995 0900 during business hours or email competencycard@olgr.nsw.gov.au
3. For more information visit www.olgr.nsw.gov.au/photocard.asp
4. Lodge this application form by:
Post
Office of Liquor,
Gaming & Racing
GPO Box 7060
Sydney NSW 2001

Deliver to
Office of Liquor,
Gaming & Racing
Level 6, 323 Castlereagh St
Haymarket NSW 2000

Email
competencycard@olgr.nsw.gov.au

THIS FORM CONTAINS FILLABLE FIELDS

PART A

DETAILS ON INTERIM CERTIFICATE (including all incorrect details)

Title

Surname

Given name

Middle name

Date of birth (dd mm yyyy)


Certficate no.
Form continues on next page...

Interim certificate amendment CC0300 1012 v.1202

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RSA/RCG
Application form

PART B

YOUR CORRECT DETAILS (must correspond with your 100 points of identity)

Which details need to be changed on your certificate? (e.g. given name and date of birth)

Please complete all following details, even if they are correct or do not show on your interim certificate
Title

Surname

Given name

Middle name

Date of birth (dd mm yyyy)


Residential address
Street no.

Street name

Town/city

State

Postcode

State

Postcode

Postal address (if different to above)


PO box or street no.

Street name

Town/city
PART C

STUDENT CONTACT DETAILS

Phone (daytime)

Phone (mobile)

Phone (home)
Email address
PART D

APPROVED TRAINING PROVIDER DETAILS

RSA Interim Certificate (please tick)

Yes

No

RCG Interim Certificate (please tick)

Yes

No

Name of Approved Training Provider(s)


Date(s) of course completion (dd mm yyyy)
PART E

DECLARATION

I declare that the information I have provided is true, correct and complete and that I have made all reasonable enquires to obtain the
information required to complete this form
I acknowledge that the failure to provide all required information may result in an inability to process your application
I acknowledge that it is an offence to provide false or misleading information
I understand that specific details I have provided may be personal information under the Privacy and Personal Information
Protection Act 1998.

Name

Signature

Date
Interim certificate amendment CC0300 1012 v.1202

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