I, the applicant:
1. Acknowledge that I/the applicant understand the information on this form.
2. Acknowledge that the accredited body (MRNSW) is collecting information in this form to provide
to the Australian Criminal Intelligence Commission (ACIC) and police agencies, for a nationally
coordinated criminal history check to be conducted.
3. Have fully and accurately completed this form, and the personal information I/the applicant, have
provided relates to me/the applicant, and contains the full name and all names previously used by
me/the applicant.
4. Acknowledge that withholding and/or providing misleading or false information on this form and
in any supplied identity documents is a Commonwealth offence and may lead to prosecution under
the Criminal Code Act 1995 (Cth).
5. Acknowledge that personal information that I/the applicant provided in this form and on the
supplied identity documents may be disclosed to the accredited body (MRNSW) (including
contractors, legal entity customers, related bodies or third parties named in Section 2 of this form in
Australia or overseas, if applicable).
6. Acknowledge that any information sent by mail or electronically, in relation to this form, including
identity documents, is sent at my/the applicant’s risk and I/the applicant, am aware of the
consequences of sending information in these ways.
7. Acknowledge that I/the applicant am aware that I/the applicant am providing consent for a
national check to be conducted on all personal information provided in this form and provided in
suppled identity documents.
8. Understand and consent to police information relating to me/the applicant, being disclosed in
accordance with the purpose identified in section 1 of this form, applicable legislation and
information release policies (including spent convictions legislation described in Australian
Government and state or territory legislation).
9. Give consent to:
a. the ACIC and police agencies using and disclosing my/the applicant’s personal information that I/
the applicant, have provided in this form and personal information contained in my supplied identity
documents to conduct a nationally coordinated criminal history check.
b. the ACIC disclosing the police information sourced from the police agencies to other approved
bodies and the accredited body (MRNSW).
c. the accredited body (MRNSW) disclosing to the legal entity customer, third parties and any
permitted offshore transfer arrangements also detailed in Section 2, my/the applicant’s personal
information and police information to assess my/the applicant’s suitability for the purpose identified
in section 1 of this form.
d. acknowledge that it is usual practice for my/the applicant’s personal information and police
information to be used by police agencies and the ACIC for law enforcement, including purposes set
out in the Australian Crime Commission Act 2002 (Cth).