This form is to be completed by a person who is either: an applicant for an individual Hydroponics Industry Dealer’s Licence, or a director of a company which has applied for a Hydroponics Industry Dealer’s Licence, or an individual applying for a Hydroponics Industry Employee Approval. All details must be completed to the best of your knowledge. It is an offence to make a statement that is false or misleading (whether by reason of inclusion or omission on any particular) in any information provided. If you have any doubt about a question please contact the Licensing Enforcement Branch on (08) 7322 3342. You MUST provide with this document, a South Australia Police, National Police Check Application PD267. This application must be partially completed online at www.police.sa.gov.au. Failure to correctly complete and supply the National Police Check Application will delay the Licence / Approval application process.
SAPOL use only	ID Card No:	Application Ref:
1. PERSONAL DETAILS
Family Name	Given Name(s)
Male Female	/ /
Date of Birth	Occupation
Current Residential Address	Post Code	State
Service Address (This is the address any official correspondence will be sent to)	Post Code	State
( )	( )
Home Phone	Work Phone	Mobile
Email
Please include ANY other names by which you have ever been known:- (This may be from birth, maiden, married, alias, changed legally or otherwise)
If NOT born in Australia, please complete the following:-
Town of Birth	Country of Birth
Have you become an Australian citizen?
Yes – Certificate number or Australian passport number:
No – Passport / identity number and country of issue:

Application Ref:
2. YOUR FAMILY DETAILS
All details must be completed to the best of your knowledge. If address or date of birth details are not known (N/K) please provide reasons in the ‘Supplementary section’ at the end of this form. Also use the section if further room is required.
(a) PARENTS / STEP PARENTS (including deceased)
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
(b) BROTHERS / SISTERS – include step or half brothers / sisters (including deceased)
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
(c) SPOUSE / PARTNER (whether or not currently residing with you)
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
(d) SPOUSE / PARTNER’S PARENTS / STEP PARENTS (including deceased)
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /

(e) SPOUSE / PARTNER’S BROTHERS & SISTERS – include step / half brothers / sisters (including deceased)
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
(f) YOUR CHILDREN – ABOVE 18 YEARS OLD (including deceased)
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
(g) OTHER PERSONS RESIDING WITH YOU (if not listed above)
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Application Ref:
3. YOUR ADDRESS HISTORY
Other than your current residential address, list addresses where you have lived in the last 10 years, including interstate and overseas. Please list from the most recent downwards. Write N/A if there are no other addresses.
Address:	(for example) 4 / 123 Brown St, Adelaide	Dates:	Feb 2005 to Dec 2009
Address:	Dates:
Address:	Dates:
Address:	Dates:
Address:	Dates:
Address:	Dates:
If you have, in the LAST 10 YEARS, resided OUTSIDE AUSTRALIA where the period spent in any one country was 12 months or more you MUST provide an original or certified copy of a POLICE CERTIFICATE (statement of Offence History) from the local law enforcement agency of each country in which you resided. This is only required if you were over 17 years of age at the time of residency.
4. OFFENCE HISTORY – you MUST answer each question
(a) Have you ever been arrested or reported for ANY offence including offences committed before the age of 18 years (do not include offences dealt with by way of Family Conference or Caution) either in Australia or overseas that was found proven, whether or not a conviction was recorded? (Do not include Expiation notices in this section)
Yes – please list details below	No – proceed to next question
Date:	State / Territory or Country:	Offence:
(b) Have you ever been issued with ANY type of expiation notice in Australia? (e.g. traffic offence, shop lifting, drug, tobacco, liquor, environmental)
Yes – please list details below	No – proceed to next question
Date:	State / Territory or Country:	Expiation notice issued for:
(c) Have you been charged or reported for any offence which has not been before court or is currently before the court?
Yes – please list details below	No – proceed to next question
Date:	State / Territory or Country:	Offence:
Application Ref:
(d) Have you been disciplined, fined or disqualified by a Tribunal, Board or other Authority (e.g. Business Licensing) in this State or another State, Territory or Country?
Yes – please list details below	No – proceed to next question
Date:	State / Territory or Country:	Offence:
(e) Are there any pending disciplinary proceedings against you?
Yes – please list details below	No
Date:	State / Territory or Country:	Offence:
SUPPLEMENTARY SECTION
Use this space to complete information to questions where you did not have enough space. Please indicate which section and question the information relates to:-
Application Ref:
AUTHORITY
I hereby consent to the release of full details of any person and any other relevant information that any Australian State / Federal / Territories Police or Law Enforcement Agency may have in its possession with reference to me. This includes any convictions imposed on me that are spent or rehabilitated (however described) under State / Territory / Federal Legislation. I acknowledge without this consent being provided, spent or rehabilitated convictions within certain States may not be disclosed. I understand some details provided in this application may be recorded and retained by SAPOL. Offences from other States/Territories will be released in accordance with their specific spent conviction and rehabilitation legislation policies. I authorise the Commissioner of Police to make any enquiries that may be relevant for Hydroponics Industry Control Act, Licensing and Approvals.
PENALTY FOR SUPPLYING FALSE OR MISLEADING INFORMATION
Section 28 – Hydroponics Industry Control Act 2009. A person must not make a statement that is false or misleading in a material particular (whether by reason of the inclusion or omission of any particular) in any information provided, or record kept, under this Act. Maximum penalty: $20,000.
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(Signature)	(Date)
(Full Name)
SAPOL use only
National Police Check Application sighted and ID verified:
(Name)	(ID)
/ /
(Date)