ࡱ> []Zc )bjbj 4Vff!8Tkd%t(%*%*%*%*%*%*%$')N%N%c%666.(%6(%66l#|$0&2屳^#%y%0%#[*6[*$$[*$06N%N%6%[* : STATUTORY DECLARATION Statutory Declarations Act 1959 Pursuant to the requirements of section 19 of the Mutual Recognition Act 1992 (Commonwealth) or section 18 of the Trans-Tasman Mutual Recognition Act 1997 (Commonwealth), a person applying to be licensed/registered in ɫƵ under mutual recognition principles must lodge a notice about certain matters that is verified by statutory declaration. Application refers to your mutual recognition application lodged in ɫƵ. State or Territory includes New Zealand. Please read this document carefully and ensure that you are able to truthfully declare all the matters set out below, then complete the statutory declaration and lodge this with your application. You are able to upload a copy as part of your online application on MyCAV. 1 Insert the name, address and occupation of person making the declaration I,1 make the following declaration under the Statutory Declarations Act1959 (Commonwealth):  2 Set out matter declared to in numbered paragraphs In relation to the occupation for which licensing/registration is sought in my Application, I DECLARE THAT: 1. I am licensed / registered for the occupation(s) in the State or Territory listed in my Application. 2. I am seeking to be licensed / registered in accordance with the mutual recognition principle (or Trans-Tasman mutual recognition principle, if applicable). 3. I have specified in my Application all the State and Territories in which I have a substantive licence / registration that is equivalent to the ɫƵn licence / registration. 4. I am not the subject of disciplinary proceedings in any State or Territory (including preliminary investigations or action that may lead to disciplinary proceedings) in relation to the occupation(s) listed in my Application. 5. My licence / registration in any State or Territory is not cancelled or currently suspended as a result of disciplinary action. 6. I am not otherwise personally prohibited from carrying on any such occupation or an equivalent occupation in any State or Territory. 7. I am not subject to any special conditions in carrying on any such an occupation or an equivalent occupation in any State or Territory as a result of any criminal, civil or disciplinary proceedings. 8. I have specified in my Application any special conditions to which I am subject when carrying on any such occupation in any State or Territory. 9. I consent to the making of inquiries of, and the exchange of information with, the authorities of any State or Territory regarding my activities in the relevant occupation(s), and otherwise regarding matters relevant to my notice. 10. I certify that I have included with my Application either the original or a complete and accurate copy of a document that is evidence of my existing licence / registration. 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 Statutory Declarations Act 1959, and I believe that the statements in this declaration are true in every particular. 3 Signature of person making the declaration 4 [Optional: email address and/or telephone number of person making the declaration] 3 45 Place 6 Day 7 Month and yearDeclared at 5 on 6 of 7 Before me, 8 Signature of person before whom the declaration is made (see over) 8 9 Full name, qualification and address of person before whom the declaration is made (in printed letters) 10 [Optional: email address and/or telephone number of person before whom the declaration is made 9 10 Note 1A person who intentionally makes a false statement in a statutory declaration is guilty of an offence, the punishment for which is imprisonment for a term of 4 years see section 11 of the Statutory Declarations Act 1959. Note 2Chapter 2 of the Criminal Code applies to all offences against the Statutory Declarations Act 1959 see section 5A of the Statutory Declarations Act 1959. A statutory declaration under the Statutory Declarations Act 1959 may be made before (1) a person who is currently licensed or registered under a law to practise in one of the following occupations: Architect Chiropractor Dentist Financial adviser Financial Planner Legal practitioner Medical practitioner Midwife Migration agent registered under Division 3 of Part 3 of the Migration Act 1958 Nurse Occupational therapist Optometrist Patent attorney Pharmacist Physiotherapist Psychologist Trade marks attorney Veterinary surgeon (2) a person who is enrolled on the roll of the Supreme Court of a State or Territory, or the High Court of Australia, as a legal practitioner (however described); or (3) a person who is in the following list: Accountant who is: a fellow of the National Tax Accountants Association; or a member of any of the following: Chartered Accountants Australia and New Zealand; the Association of Taxation and Management Accountants; CPA Australia; the Institute of Public Accountants Agent of the Australian Postal Corporation who is in charge of an office supplying postal services to the public APS employee engaged on an ongoing basis with 5 or more years of continuous service who is not specified in another item in this list Australian Consular Officer or Australian Diplomatic Officer (within the meaning of the Consular Fees Act 1955) Bailiff Bank officer with 5 or more continuous years of service Building society officer with 5 or more years of continuous service Chief executive officer of a Commonwealth court Clerk of a court Commissioner for Affidavits Commissioner for Declarations Credit union officer with 5 or more years of continuous service Employee of a Commonwealth authority engaged on a permanent basis with 5 or more years of continuous service who is not specified in another item in this list Employee of the Australian Trade and Investment Commission who is: (a) in a country or place outside Australia; and (b) authorised under paragraph 3 (d) of the Consular Fees Act 1955; and (c) exercising the employees function at that place Employee of the Commonwealth who is: (a) at a place outside Australia; and (b) authorised under paragraph 3 (c) of the Consular Fees Act 1955; and (c) exercising the employees function at that place Engineer who is: a member of Engineers Australia, other than at the grade of student; or a Registered Professional Engineer of Professionals Australia; or registered as an engineer under a law of the Commonwealth, a State or Territory; or registered on the National Engineering Register by Engineers Australia Finance company officer with 5 or more years of continuous service Holder of a statutory office not specified in another item in this list Judge Justice of the Peace Magistrate Marriage celebrant registered under Subdivision C of Division 1 of Part IV of the Marriage Act 1961 Master of a court Member of the Australian Defence Force who is: an officer a non-commissioned officer within the meaning of the Defence Force Discipline Act 1982 with 5 or more years of continuous service a warrant officer within the meaning of that Act Member of the Australasian Institute of Mining and Metallurgy Member of the Governance Institute of Australia Ltd Member of: the Parliament of the Commonwealth the Parliament of a State a Territory legislature a local government authority Minister of religion registered under Subdivision A of Division 1 of Part IV of the Marriage Act 1961 Notary public, including a notary public (however described) exercising functions at a place outside the Commonwealth the external Territories of the Commonwealth Permanent employee of the Australian Postal Corporation with 5 or more years of continuous service who is employed in an office providing postal services to the public Permanent employee of a State or Territory or a State or Territory authority a local government authority with 5 or more years of continuous service, other than such an employee who is specified in another item of this list Person before whom a statutory declaration may be made under the law of the State or Territory in which the declaration is made Police officer Registrar, or Deputy Registrar, of a court Senior executive employee of a Commonwealth authority Senior executive employee of a State or Territory SES employee of the Commonwealth Sheriff Sheriffs officer Teacher employed on a permanent full-time or part-time basis at a school or tertiary education institution ;<=>pY ^ o w    & ' ( ) * ucucuuuuuuuuuuuuuuuuuuu#hZh_O6CJOJQJ^JaJ hZh_OCJOJQJ^JaJh_OCJOJQJ^JaJ/hKh_O6B*CJOJQJ]^JaJph)hKh_OB*CJOJQJ^JaJph1hKh_OB*CJOJQJ^JaJnH phtH /hKh_O5B*CJOJQJ\^JaJphh_OCJOJQJ^JaJ&<=>   ' ( ) * + , L$If^`Lgdxgd_O $^a$gd_O$d-DM a$gd_O$d-DM `a$gd_Ogd_O* + , - . v w x z { | } ~  ̬̽zhhWHHHHh_O5CJOJQJ^JaJ hEuh_OCJOJQJ^JaJ#hEuh_O6CJOJQJ^JaJ#hmXh_O6CJOJQJ^JaJh_OCJOJQJ^JaJ#hmXh_OCJH*OJQJ^JaJ hmXh_OCJOJQJ^JaJh_O6CJOJQJ^JaJ#h1!h_O6CJOJQJ^JaJ h1!h_OCJOJQJ^JaJ h1!h_OCJOJQJ^JaJ, w x | } ~  $Ifgd$$If^a$gd $If^gdL$If^`Lgd    u u 23ABu%&3456d01ddABdnpxy{ƷƷh_OCJOJQJ^JaJ hEuh_OCJOJQJ^JaJ hmXh_OCJOJQJ^JaJh_O6CJOJQJ^JaJ#h1!h_O6CJOJQJ^JaJ h1!h_OCJOJQJ^JaJh_O#hmXh_O5CJOJQJ^JaJ5   B&yyggggg$$If^a$gd$$If^a$gd$  $If^a$gdL$If^`LgdQkd$$Ifl0*644 layt 1y*+,-23456sQkdJ$$Ifl0*644 layt $If^gd$$If^a$gd $$Ifa$gd$$If^a$gd )*+,-//12345678bcdeоЦtcTTh_OCJH*OJQJ^JaJ h1]h_OCJOJQJ^JaJ h1]h_OCJOJQJ^JaJh_O6CJOJQJ^JaJ#h1!h_O6CJOJQJ^JaJh_O&hL&h_O56CJOJQJ^JaJ#hL&h_O5CJOJQJ^JaJ hmXh_OCJOJQJ^JaJ hEuh_OCJOJQJ^JaJh_OCJOJQJ^JaJ 6cdeCDQkd$$Ifl0*644 layt $If^gdL$If^`Lgd?@BCDNOPQRS <ijklmȷȦȗȗh_OCJH*OJQJ^JaJ hmXh_OCJOJQJ^JaJ h1!h_OCJOJQJ^JaJ#h1!h_O6CJOJQJ^JaJh_O6CJOJQJ^JaJh_O#hmXh_OCJH*OJQJ^JaJ7DOPQL$If^`LgdQkd$$Ifl0*644 layt $If^gdjkmnopqruvw $If^gdL$If^`LgdQkd($$Ifl0*644 laytmnopqrtuvwx~?^_`fz~'FZ[yeyVh_O5CJOJQJ^JaJ&hWlh_O56CJOJQJ^JaJ#hWlh_O5CJOJQJ^JaJh_OCJOJQJ^JaJ htQ6h_OCJOJQJ^JaJ#htQ6h_O6CJOJQJ^JaJh_O#hmXh_OCJH*OJQJ^JaJh_OCJH*OJQJ^JaJ hmXh_OCJOJQJ^JaJh_OCJOJQJ^JaJwx`[()rrrrrr<7$8$H$^gd_O x^gd_O $x^gd_O <^gd_O <^gd_OQkdr$$Ifl0*644 layt [_gln~'(H()-5:<H 8GHij%vw%Uůŝ"h_OCJOJQJ^JaJnH tH +h8jh_O6CJOJQJ^JaJnH tH (h8jh_OCJOJQJ^JaJnH tH h8jh_OCJOJQJ^JaJ(h6h_OCJOJQJ^JaJnH tH 9Hjwmu!2Nl9K<7$8$H$^`gd_O & F<7$8$H$gd_O & FG<7$8$H$^`Ggd_O<7$8$H$^`gd_OUklmtu !%12MNkl%89@JKl{    ; 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