Approved form AF2002-28

approved by the Commissioner of Fair Trading on 12 March 2002 under the

Second-hand Dealers Act 1906, s18 (Approved Forms)

Second-hand Dealers Act 1906
(see s 3)

Australian Capital Territory

Consent to obtain personal information

(See attached form entitled Consent to obtain personal information)

OFT.SHD.AFP.01

STAFF-IN-CONFIDENCE
(when completed)

Commonwealth of Australia
CONSENT TO OBTAIN PERSONAL  INFORMATION
(for categories where NO EXCLUSION has been granted from spent convictions legislation)

FULL NAME - BLOCK LETTERS - USE INK

I ,

am an applicant for the issue of, or the renewal of, a Second-hand Dealers Licence in  the Australian Capital Territory (ACT), and hereby :

(i)	acknowledge that I have read the General Information document provided with this form and understand that I do not have to disclose old protected convictions information, which is described under the heading "Spent Convictions Scheme" in the General Information document ;

(ii)	certify that the personal information I have provided on both the front and back of this form relates to me and is correct ;

(iii)	consent to the Commissioner of Fair Trading for the ACT forwarding this form to the Australian Federal Police (AFP) and / or the Police Services of all or any of the States or Territories of the Commonwealth of Australia and to the Australian Federal Police providing relevant information to the Commissioner of Fair Trading for the ACT for the purpose of enabling me to obtain a licence under the Second-hand Dealers Act 1906 of the ACT ;

(iv)	consent to the AFP or other relevant Australian Police Service(s) extracting from their records details of traffic violations and criminal and/or traffic records relating to me pending before a court, and/or details of convictions or findings of guilt which have been recorded against me and which are not covered by Part VII of the Crimes Act 1914, dealing with "spent convictions" and providing any such details to the Commissioner of Fair Trading for the ACT ;

(v)	acknowledge that any information provided by me in this form or by the police as a result of the records check my be taken into account by the Commissioner of Fair Trading for the ACT in assessing my suitability to hold a licence under the Second-hand Dealers Act 1906.

/	/	20

Signature of applicant	Date

Complete both sides of this form

Office use only

PROMOTING CONSUMER CONFIDENCE
Manager
Registration & Client Services Unit Office of Fair Trading
ACT Department of Justice and Community Safety GPO Box 158
Canberra City ACT 2601
Level 2, GIO House, City Walk, Canberra City Telephone:  (02) 6205 1778

Complete both sides of this form

OFT.SHD.AFP.02

Male	Female

Surname (present)

All other surnames used

Christian or given names

Sex

Date of birth

Town / City of birth

State  /  Country of birth

/	/

Contact phone number	Driver licence number	State (driver licence issued)

PERSONAL PARTICULARS	NO EXCLUSION (REVERSE)
PERMANENT RESIDENTIAL ADDRESS OVER LAST TEN YEARS
If full details of previous address are unavailable, details of town(s) and state(s) will suffice.	Attach list if insufficient room.	If actual dates are unavailable, of year of residence will suffice.	details	
Current	
/	Period of residence
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Tick boxes

(i)

Are you the subject of any criminal charge(s) still pending before a court ?

Yes

No

(ii)

Do you have any conviction(s) or finding(s) of guilt which are less than ten (10) years old, or any juvenile conviction(s) or finding(s) of guilt which are less than five (5) years old ?

Yes

No

(iii)

Do you have any conviction(s) or finding(s) of guilt which are over ten (10) years old [or five (5) years for  juvenile conviction(s) or finding(s) of guilt] where
the sentence imposed was greater than thirty (30) months imprisonment ?

Yes

No

If you answered YES to any of the above questions, please ATTACH DETAILS.

CRIMINAL / TRAFFIC CHARGE, CONVICTION OR PECUNIARY PENALTIES

User Code: 460

AFP use only

RECORDED / NOT RECORDED
Note: As fingerprints do not accompany your request, the Australian Federal Police cannot guarantee, in any manner, that the information supplied herewith concerns the individual in whom you are interested.

Signature
Date

 	

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For - Commissioner, Australian Federal Police