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Form30001 532063
Form30001 532063
FORM30001
UCA532063
STD81795
Section 1: Applicant
I, Esteban Calderon, of 2A Shipley Place Westminster in the state of WA, 6061 make the following declaration under the Commonwealth
Statutory Declaration Act 1959 and so solemnly and sincerely declare that:
1. The work submitted for the White Card course was my own work.
2. I have received no assistance from anyone (course trainer excluded) in the completion of the White Card course assessment.
3. I have identified myself truthfully for the White Card course undertaken
4. The time, date, place, and the number of the hours taken by me to complete the online course and assessment is:
10 hrs hours
a. Time taken to complete course: ______________
25/11/2014
b. Date course was completed: _______________
Shipley Place Westminster 6061
c. Place course was completed (address or physical location): 2A
_________________________________________________
I make this solemn and sincere declaration conscientiously believing the same to be true, and I understand that a person who
intentionally makes a false statement in a statutory declaration is guilty of an offence under section 11 of the Commonwealth
Statutory Declaration Act 1959, AND I believe that the statements in this declaration are true in every particular.
___________________________________________________________
Signature of Applicant (SIGN IN FRONT OF AN AUTHORISED PERSON)
__________________
Date
_______________________________________ (Qualification)
Signature
Section 3: Observer (Any person who witnessed you undertaking the online assessment)
I, ____________________________________ (Name), of _____________________________________________________________
___________________________ (Address) in the state of___________ postcode________, contact phone number ______________
Do solemnly and sincerely declare that I am over the age of 18 years and that:
1.
2.
3.
I have observed the course participant undertaking the course assessment and the mode of assessment was undertaken online.
I confirm that the course participant is one and the same person as the person who undertook the course assessment on the
said time, date and place stated in the Applicants declaration above.
I know that it is an offence to make the declaration should it be false in any material particular and I believe that the statements
made in this declaration are true in every particular.
_________________________________________________________
Signature of declarant/deponent (the Observer)
__________________
Date
Instructions
You must return BOTH the Statutory Declaration, AND a
Certified Copy of Your Identification.
You can return these by either uploading them to our
website at http://www.eot.edu.au/account OR by posting
them 813/1 Abel Place, Cronulla, NSW, AUS, 2230 (Please do
NOT use Registered Post).
Statutory Declaration
ALL sections of this form must be completed and returned on
one (1) page.
Section 1 is to be completed by the student, and signed in
front of an authorised person, who will then complete
section 2 and may also certify your identification documents.
2.