Australia | Criminal | Australia Federal Police (AFP) | National Police Check (NPC)

Instructions

Information required:

You must complete and sign the AFP Form (found below)
You must provide 100 points of ID (explained below)

Tips for completing the form:

Please complete all sections in BLOCK LETTERS. This can be either typed of handwritten.

Page 1 Section 1 – NPC (National Police Check) Code

In section 1, you must provide an NPC code. This code classifies your purpose for completing a National Police
Check. This code is based off the job you are completing a check for, and the location of this job.
• If you are an Amazon Flex applicant located in ACT, please use Code Number 30 (Pre-Employment/Standard
Disclosure – in the ACT)
• If you are an Amazon Flex applicant located in NSW, SA, NT, WA, VIC, or QLD please use Code Number 39
(General Purpose/Standard Disclosure)
Page 1 Section 2 – Applicant Details

This area will need to be filled with your personal details.

• Please provide your full and precise name on all forms (must match full name listed on ID documents)
o If you have more than 2 former names, please provide these on page 4.
• If you need to provide additional addresses, please provide these on page 4.
• You DO NOT need to complete the sections for your Telephone Number, Gender, Australian Driver’s License
Number.
• Please keep in mind all date fields should be in DD/MM/YYYY format.
Page 2 Section 3, 4 & 5

You DO NOT need to complete section 3, 4, and 5. These sections are prefilled.

Page 2 Section 6 - Consent

This section requires your physical signature and date.
Electronic signatures are accepted by stylus or finger.
Typed signatures will NOT be accepted by the AFP.

Tips for 100 Points of ID:

100 points of ID must be provided. This is 2 or more ID documents that need to be scanned and uploaded
with this form. The acceptable documents and their point values are listed on the last page.

When scanning documents, please provide us with high-resolution copies. Incomplete release forms and documents
that are not clear or legible will delay completion of the criminal search.

All documents and the completed AFP form (signed) must be provided to Accurate. You can provide them as one combined
attachment or as separate attachments by using the “upload” document button.

Australian | Criminal | Australia Federal Police (AFP) | National Police Check (NPC) | Instructions | Page 1 of 1
 Australian Federal Police
National Police Check (NPC) Application Form
Please complete this form by referring to the Application Completion Guide.

1. Purpose of NPC Code Number

39
Enter the relevant code number from the table at Section 1: Purpose of NPC on the Application completion Guide
(e.g. Fire fighting/prevention – in the ACT = Code No 15)
If a code is not specified this application will NOT be processed and will be returned for amendment.

2. Applicant Details - Use BLOCK LETTERS and black ink. Mark check boxes with a cross (X).

Current Family Name

MERCER
All Given Names
CINDIE JOYCE
Date of Birth (DD/MM/YYYY)
/ /
15/05/1975
Previous or Other Names by which you are known or have been formerly known must be listed below (eg. maiden, deed poll).
If more room is required, list on separate sheet, sign and send with this application form. Additional information sheet included

Family Name: (include all name changes and maiden name) Given Names Date of Birth

/ /
/ /
Place of Birth Town State
VICTORIA MELBOURNE VIC
Country
AUSTRALIA
Contact Telephone Number
0438905587
Australian Drivers Licence Number Issuing State
4250959 WA Copy Attached

Current Residential Address – Complete in FULL

Unit No. Street No. Street Name / Street Type

9 CARSON COURT
Suburb/City Post Code

GOSNELLS 6110
State Country Residency From

WA AUSTRALIA / /
7/25/09

Previous Residential Address – Complete in FULL

Unit No. Street No. Street Name / Street Type

3 1 BILCH STREET
Suburb/City Post Code

GOSNELLS 6110
State Country Residency From

WA AUSTRALIA / /
11/5/20

Form CR500-21 Version 1.0 Page 1 of 2

3. Employer/Organisation Details (For use by AFP Account holders only)

Employer/Organisation name Client Code Client Reference Number

VerifyNow Pty Ltd and their client 3172 39

4. Mailing Address for Police Certificate

The National Police Certificate will be posted to the account holder listed at Section 3 of this application.

5. Fingerprints

Please note that a fingerprint check is only required under very limited circumstances. Please ensure that you are actually required to
have a fingerprint check conducted before going to the expense of this level of check by checking with the organisation/department
requesting the check.

Is a fingerprint check required? Yes No X If yes, fingerprints must be submitted with this form. In addition choose only
one of the below statements. For information on fingerprint checks see Section 5: Fingerprint Checks on the Application Completion
Guide.
I have attached:
(a) fingerprints taken by another police jurisdiction OR

(b) fingerprints taken by the AFP and not charged when taken OR

(c) fingerprints taken by the AFP and charged when taken - receipt of payment must be supplied with this form

6. Consent

i. I acknowledge I have read the Application Completion Guide for this application form (pages 1 – 5) and I am aware exclusions from spent
convictions legislation may apply to some categories of NPCs.
ii. The personal information I have provided on this form (including fingerprints if supplied) relates to me and is correct.
iii. I acknowledge the details contained on this form, including fingerprints where relevant, will be forwarded to the AFP, Australian Criminal
Intelligence Commission, and/or the Police Services of the States or Territories of the Commonwealth of Australia.
iv. I consent to the AFP and any other Australian police force extracting details of any convictions, findings of guilt or pending court proceedings
relating to me, including in relation to any traffic offence, and providing that information to me or to the Employer/Organisation named in
Section 3 above, as approved or to another person agency as named in Section 4.
v. I acknowledge the information provided on this form will not be used without my prior consent for any other purpose, unless otherwise
authorised by law.
vi. I acknowledge that any information provided on this form or disclosed by the police as a result of the records check may be taken into
account by the organisation mentioned in (3) above or any organisation to whom I present the results of the records check in assessing my
suitability to receive the entitlement.

Applicant’s Signature Date / /

15/10/2021

If you are under 18 years of age please provide consent below from a parent/guardian.

Parent/Guardian Signature Date / /

Parent/Guardian name printed in full

Form CR500-21 Version 1.0 Page 2 of 2

 AFP NPC FORM-5025

Attachment B: Other names you have used (use only if required)

Former Name Also known as Date of Birth: 1 5 0 5 1 9 7 5 (DD MM YYYY)

Family Name / Surname :

First Name / Given Name:

Other Given Names:

Former Name Also known as Date of Birth: (DD MM YYYY)

Family Name / Surname :

First Name / Given Name:

Other Given Names:

Former Name Also known as Date of Birth: (DD MM YYYY)

Family Name / Surname :

First Name / Given Name:

Other Given Names:

Attachment C: Previous Residential Address (use only if required - must not be a PO Box or Business Address)

Unit No / Street No / 9 C A R S O N C O U R T
Street Name:

Suburb / Town / Locality:

Postcode: State:

Country:

Date you started living at this address: (DD MM YYYY)

Unit No / Street No /
Street Name:

Suburb / Town / Locality:

Postcode: State:

Country:

Date you started living at this address: (DD MM YYYY)

Unit No / Street No /
Street Name:

Suburb / Town / Locality:

Postcode: State:

Country:

Date you started living at this address: (DD MM YYYY)

Optional Attachment
 CHIEF FINANCIAL OFFICER

Criminal Records Vetting Team

GPO Box 401 Canberra City ACT 2601
Telephone 02 5127 1198
Email [email protected]
www.afp.gov.au
ABN 17 864 931 143

Application Completion Guide

Section 1: Purpose of NPC
Applicants must choose one purpose only from the following list. Identify the relevant code and
insert in the purpose code box on page 1 of the NPC form.

Code Working in the Australian Capital Territory (ACT) Offences recorded in the ACT that will be
number released (Spent Convictions Act 2000)
8 Hospital Employment – in the ACT ACT - All offences. Other State/Territory offences as
legislation permits
9 Security Licence (Security Guard) - in the ACT ACT - All offences. Other State/Territory offences as
legislation permits
10 Aged Care Provider/Worker – in the ACT ACT - All offences. Other State/Territory offences as
legislation permits
11 Brothel or Escort Agency Owner/Operator/Interested Party – in ACT - All offences. Other State/Territory offences as
the ACT legislation permits
12 Child Care Provider/Worker – in the ACT ACT - All offences. Other State/Territory offences as
legislation permits
13 Disabled Care Provider/Worker – in the ACT ACT - All offences. Other State/Territory offences as
legislation permits
14 Explosives/Fireworks Permit (where an ASIO check is required) Unspent offences
– in the ACT
15 Fire Fighting/Prevention – in the ACT Unspent offences and Arson or Attempted Arson
offences
16 Firearms Licence/Permit – in the ACT ACT - All offences. Other State/Territory offences as
legislation permits
17 Interactive Gambling Licence/Casino Employee – in the ACT ACT - All offences. Other State/Territory offences as
legislation permits
18 Prison Officer - in the ACT ACT - All offences. Other State/Territory offences as
legislation permits
19 Child/Aged/Disabled Care Provider/Worker – in the ACT ACT - All offences. Other State/Territory offences as
legislation permits
20 Working in a School – in the ACT ACT - All offences. Other State/Territory offences as
legislation permits
21 Teacher/Teacher’s Aide – in the ACT ACT - All offences. Other State/Territory offences as
legislation permits
30 Pre-Employment/Standard Disclosure – in the ACT Unspent offences

Form CR500-21 Version 1.0 Page 1 of 6

 Commonwealth Purpose/Employment Offences recorded in the Commonwealth that will
be released (Part VIIC Crimes Act 1914)
22 Aged Care Staff/Volunteers Unspent offences and offences against the person where
State/Territory legislation permits
23 Aged Care Key Personnel Unspent offences

24 Australian Securities and Investments Commission - ASIC All Commonwealth offences. Other State/Territory
Employee offences as legislation permits
25 Australian Securities and Investments Commission - Unspent offences
Financial Licensing
26 AUSTRAC Employee/Consultant All Commonwealth offences. Other State/Territory
offences as legislation permits
27 Care of Intellectually Disabled Persons Unspent offences and offences against the person where
State/Territory legislation permits
28 Care, Instruction or Supervision of Children Unspent offences a) a sexual offence; or b) any other
offence against the person if the victim of the offence
29 Civil Aviation Safety Authority - ASSC Unspent offences

31 Employee with Access to Secret or Top Secret Information All Commonwealth offences. Other State/Territory
offences as legislation permits
32 Immigration Detention Centre Employment Unspent offences and offences involving violence where
State/Territory legislation permits
33 Immigration/Citizenship – Australia All Commonwealth offences. Other State/Territory
offences as legislation permits
34 Law Enforcement/Intelligence or Security Agency All Commonwealth offences. Other State/Territory
Employee/Consultant (NB NOT private Security) offences as legislation permits
35 Overseas Visa - Supply to a Country other than Australia All Commonwealth offences. Other State/Territory
offences as legislation permits
36 Superannuation Trustee/Custodian/Investment Manager or Unspent offences and offences in respect of dishonest
Responsible Officer of a body corporate that is a trustee, conduct where State/Territory legislation permits
37 Care, Instruction or Supervision of Children/Care of Unspent offences as well as (i) a sexual offence, and
Disabled Persons/Aged Care Staff/Volunteers (ii) any other offence against the person if the victim
40 Other Commonwealth Purpose ONLY Unspent offences

41 Overseas Employment - General Employment All Commonwealth offences. Other State/Territory

offences as legislation permits
42 Overseas Employment - Aged/Disabled Care All Commonwealth offences. Other State/Territory
offences as legislation permits
43 Overseas Employment - Teaching All Commonwealth offences. Other State/Territory
offences as legislation permits
44 Overseas Employment - Working with Children All Commonwealth offences. Other State/Territory
offences as legislation permits
45 Overseas Employment - Nursing, Hospital Employment All Commonwealth offences. Other State/Territory
offences as legislation permits

Pre-Employment/Standard Disclosure Where ACT or Commonwealth Legislation does not Apply

39 General Purpose/Standard Disclosure Unspent offences as Commonwealth/State/Territory

legislation permits

Form CR500-21 Version 1.0 Page 2 of 6

 Section 2: Applicant details
Please ensure ALL applicant details are provided including all current and previous names,
telephone contact numbers, drivers licence details etc.
If there is insufficient room, please attach a separate sheet, ensuring that it is signed and dated.

Section 3: Employer/Organisation details

This section relates to AFP account holders only and should not be used unless previously
advised.

Section 4: Mailing Address of Police Certificate

The National Police Certificate will be mailed to the organisation listed at Section 3.

Section 5: Fingerprint Checks

Are only required where there is a legislative requirement for such a check to be conducted. The
employer or organisation requiring the NPC will advise you if this is necessary.

These fingerprints must be included at the time of submission.

An additional cost and processing time is associated with this service. Details are available on
the AFP website or use the link – http://www.afp.gov.au/what-we-do/police-checks/national-
police-checks.aspx

Fingerprints can be taken by your local police jurisdiction or the AFP. Where fingerprints are
taken by the AFP and the AFP charges for this service a receipt must be obtained and supplied to
Criminal Records with this application.

Section 6: Consent
This section must be signed by the applicant. If a parent/guardian has signed in the consent
section they consent to the AFP conducting a NPC on their son/daughter/ward.

The use of electronic signatures that can be electronically certified/verified such as Adobe
“Certificate” is permitted. We do not accept electronic signatures that cannot be electronically
certified/verified such as Adobe “Fill and Sign”. Application forms with electronic signatures that
cannot be certified/verified will be returned for amendment.

Form CR500-21 Version 1.0 Page 3 of 6

 Spent Convictions Legislation
The aim of spent convictions legislation is to prevent discrimination on the basis of certain
previous convictions. Spent convictions legislation limits the use and disclosure of older, less
serious convictions and findings of guilt.

There are some offences excluded from being spent where the check is required for certain
purposes as indicated in the table above – these offences will be released regardless of how old
they are.

Where a record exists within an Australian police jurisdiction, relevant spent conviction
legislation/policies governing the release of that information for that jurisdiction will be applied.
As a result certain convictions will not be released provided this is in accordance with the
relevant legislation/policies.

For Commonwealth records the AFP applies the provisions within Part VIIC of the Crimes Act
1914 and for ACT records provisions within the ACT Spent Convictions Act 2000 are applicable.
If further information or clarification is required please contact the individual jurisdiction where
the record is held.

Provision of False or Misleading Information

You are asked to certify that the personal information you have provided on this form is correct.
Where your check is for employment related purposes and the result is to be provided to your
employer or other organisation, discovery of any false or misleading information may be
reported by the AFP and may impact on the decision being undertaken by the employer or
organisation.

The AFP provides information, with your consent, to the employer or organisation but takes no
part in any subsequent assessment.

Disputed Record Enquiries

If you believe the information provided on your police certificate is incorrect or inaccurate
an online Disputed Record form is available from the AFP website. This form should be
forwarded to the AFP through the agency or organisation with whom you have lodged your
application for a National Police Check.

Include any additional information or documents supporting your enquiry to enable the AFP to
more accurately assess your application. In some instances the AFP may require comparison
fingerprints to resolve some disputes. Applicants will be notified in such instances.

The Privacy Commissioner is responsible for ensuring the protection of private information
relating to individuals. This includes investigating instances where information has been
released improperly or incorrectly. An individual who believes the standards dealing with
disclosure and use of old conviction information have been breached may apply to the Privacy
Commissioner for an investigation of the matter. The phone number is 1300 363 992.
The following requirements must be met when submitting an AFP National Police Check (NPC).

Form CR500-21 Version 1.0 Page 4 of 6

 Account Customer - Completion Check List

Failure to meet the required standards will result in the form being returned for amendment.

o Ensure Section 1 Purpose of NPC has been completed.

o Acceptable identification totaling 100 points must accompany the application unless
you have been otherwise advised. Do not send original documents.

o Guide to identity documents is at page 6.

o Ensure all the necessary details have been completed and the form is signed and dated.

o If completing by hand use BLOCK LETTERS and black ink.

o Mark the appropriate check boxes with a cross (X).

o All previous or other names by which you are known or have been formerly known,
including maiden name, must be listed in full on the form or on an enclosed additional
sheet.

o Any attachments with additional information must be signed by the applicant.

o The form must be submitted no more than three months after being signed by the
applicant.

o If the applicant is under 18 years of age the form must be signed by a parent/guardian.

o Do not send the Application Completion Guide to the AFP. Please retain this for your
reference.

Form CR500-21 Version 1.0 Page 5 of 6

 Proof of identity
A minimum of 100 points of identification has to be provided with the application.

You must supply at least ONE Primary document Required on Points

Foreign documents must be accompanied by an official translation document Worth
N = Name
P = Photo
A = Address
S = Signature

Primary Documents
Foreign Passport (current) N–P 70

Australian Passport (current or expired last 2 years but not cancelled) N–P 70

Australian Citizenship Certificate N 70

Full Birth Certificate (not extract) N 70

Certificate of Identity issued by the Australian Government to refugees and non-Australian citizens N 70
for entry to Australia
Australian Driver Licence/Learner’s Permit N–A–P 40

Current (Australian) Tertiary Student Identification Card N–P 40

Photo identification card issued for Australian regulatory purposes (e.g. Aviation/Maritime Security
N–P 40
Identification, security industry etc)
Government employee ID (Australian Federal/State/Territory) N–P 40

Defence Force Identity Card (w/photo or signature) N–P 40

Working With Children Check card N 40

Secondary Documents
Department of Veterans Affairs (DVA) card N–A 40

Centrelink card (with reference number) N–A 40

Birth Certificate Extract N 25

Birth card (NSW BDM only) N 25

Medicare card N 25

Credit card or account card N–S 25

Australian Marriage certificate (Registry office issue only) N–S 25

Decree Nisi / Decree Absolute (Registry office issue only) N–S 25

Change of name certificate (Registry office issue only) N–S 25

Bank statement N–A 25

Property lease agreement – must be for current address N–A 25

Taxation assessment notice N–A 25

Australian Mortgage Documents N–A 25

Rating Authority – eg Land Rates N–A 25

Utility Bill – electricity, gas, telephone (less than 12 months old) N–A 20

Reference from Indigenous Organisation N–A 20

Documents issued outside Australia (equivalent to Australian documents of at least 20
20
points). Must have official translation attached.

Form CR500-21 Version 1.0 Page 6 of 6