POLICE CHECK AUTHORISATION

1. Do you have any convictions, findings of guilt and/or pending charges against you, in any Australian State
that are less than 10 years old (five for juvenile offences)?
Yes ✔ No

2. Do you have any convictions, findings of guilt and/or pending charges against you in another country that
are less than 10 years old (five years for juvenile offences)?
Yes ✔ No

3. Do you have any convictions for offences where the sentence imposed involved imprisonment for any period
of time?
Yes ✔ No

If you answered YES to any of the above questions, please provide details:

By signing below, you hereby:

a) Acknowledge that all information is true and correct, and any deliberate falsification will result in immediate
termination of employment with Staff Australia Payroll Services Pty Ltd.

b) Authorise for Staff Australia Payroll Services Pty Ltd to complete a national police check when deemed necessary to
determine suitability for employment.

c) Acknowledge that results received may be disclosed to Staff Australia’s clients for whom confirmation of relevant
criminal activity is a pre-requisite.

Elizabeth
First Name: __________________________________________________________________________________________

Acheampong
Surname: ____________________________________________________________________________________________

Signature: __________________________________________ Date: 18/08/2023

______________________________

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© Staff Australia – Making People Our Business 1

Effective: 15/06/2020
This publication is confidential information of Staff Australia Payroll Services Pty Ltd. Document ID: D211
No part of it may be copied, shared, or distributed without prior written permission from Staff Australia Payroll Services Pty Ltd. Revision: 6