appointment - authorised bushfire volunteer...discuss the matter with my brigade captain and...

APPOINTMENT - AUTHORISED BUSHFIRE VOLUNTEER

PERSONAL DETAILS

BRIGADE

Title: MR / MRS / MS / MISS

Surname:

Given Names: Preferred Name:

Address:

Postcode: State:

Postal: Postcode: State:

Date of Birth: / /

Telephone: Home: Work: Mobile:

Email Address:

Driver’s Licence/s: Class: Expiry: State/Territory of issue:

Next of Kin: Relationship:

Home address:

Telephone: Home: Work: Mobile:

Qualifications / Experience / Training:

Fire Fighter 1 (FF1) Qualified: YES / NO If YES, Year Completed:

of 3

ABV #


DECLARATION

Name:

I am over the age of 16. I hereby apply for appointment as an Authorised Bushfire Volunteer (ABV) and agree to observe all

rules, regulations and procedures in accordance to the Bushfires Management Act 2016, General Orders, the Bushfires NT Standard Operating Procedures and Bushfires NT Volunteer Code of Conduct.

I undertake to advise the Executive Director of Bushfires NT if at any time particulars provided by me in this application change, or I am no longer able to carry out the duties I may be called upon to perform.

By signing the document below, I certify that I have read and understood the above declarations and to the best of my knowledge the information provided by me in this application (and any attachments I have included with this application) is true and correct.

Signature: Date: ____/___/____

Parent / Guardian’s Signature: Date: ____/___/____ (if under 18)

Endorsement of Volunteer Bushfire Brigade Captain Application:

Supported Not Supported

Name:

Signature: Date: ____/____/____

Approved by Executive Director of Bushfires NT Application:

Approved Not Approved

Name:

Signature: Date: ____/____/____

Volunteer Advised Date: ____/____/____

ABV #


IDENTITY CARD

An Authorised Bushfire Volunteer identity card is a personally recognised form of identification and must be carried at all times when acting in the capacity as an Authorised Bushfire Volunteer.

A person who ceases to be an Authorised Bushfire Volunteer is to return the identity card to Bushfires NT within 21 days after their cessation.

Note: A digital photograph (including head and shoulders) against a plain background is to be supplied. If you do not have a digital photograph, Bushfires NT administration can arrange for the photo to be taken.

Please ensure if submitting this application electronically the photograph of yourself is correctly titled with your name.

Details (please print in CAPITALS):

Full Name:

Brigade:

Signature box (sign with a black marker pen, preferably using the whole box for your signature):

ABV #

APPLICATION FOR APPOINTMENT - AUTHORISED BUSHFIRE VOLUNTEER

MEDICAL DECLARATION Please complete one of the declarations below

I, (Full Name):

declare that I have no previous or existing injuries that prevent me from performing duties as an Authorised Bushfire

Volunteer.

If I develop a condition or injury that impedes my ability to perform the duties of an Authorised Bushfire Volunteer, I will

discuss the matter with my brigade captain and together we will decide the most appropriate pathway, whether this means

different duties, or to stand down as an active firefighter for the duration of the complaint/injury.


I, (Full Name):

declare that my ability to perform duties as an Authorised Bushfire Volunteer is restricted by the medical condition/s listed

below .

I agree to discuss these restrictions with the Executive Director, and understand the Executive Director will advise my brigade

captain of any agreed restrictions.


PRIVACY STATEMENT: The purpose of collection of this information is to allow the Executive Director of Bushfires NT to determine whether an applicant will be able to manage the demands of the appointment. All information collected will be retained in accordance with requirements of the Commonwealth Privacy Act 1988.

ABV #

Working in partnership with the community to ensure a safe and resilient Northern Territorywww.pfes.nt.gov.au/safent Page 1 of 4

Phone 1800 723 368 (1800 SAFENT) Email [email protected] SAFE NT - NT Police GPO Box 39764 Winnellie NT 0821

SAFE NT Save time and APPLY ONLINEhttps://forms.pfes.nt.gov.au/safent/

Ground Floor, 37 Woods Street DarwinOpening HoursMonday - Thursday 8.30am - 4.30pm Friday 9.30am - 4.30pm

NATIONAL POLICE CHECKC

OFFICE USE ONLY

Date Received / / CNI PN

Receipt No Lodged at Entered

CHECK REQUIRED (this section must be completed)

FINGERPRINT & NAME CHECK* NAME CHECK NAME CHECK VOLUNTEER CONCESSION - Complete Section E

* Call (08) 8985 8985 for information and bookings. Visit www.pfes.nt.gov.au/safent for a list of current fees.

SECTION A - DETAILS OF APPLICANT (this section must be completed)

Title: Mr Mrs Miss Ms Sex: Male Female

Family name/surname

First given name Other given name/s

Daytime contact Mobile number

Email address

Date of birth / / (dd/mm/yyyy)

Place of birth Town / City State Country

Other Names: Have you been known by any other name? eg. name before marriage, alias, changed by deedpoll.

Maiden name Former name Also known as Given name/s Surname

OR OR

Former name Also known as Given name/s Surname

OR

Please attach a separate sheet to list other names that you have been previously known as.

Australian Postal Address PO Box number/Street number/Street name Suburb/town State Postcode

Please check all details, including postcode, are correct. SAFE NT takes no responsibility where undeliverable information is provided.

Current Residential Address (must not be a PO Box or Business Address) (A current residential address must be supplied in order to process this application)

Street number/Street name Suburb/town State Postcode

(Police/TBC)

Country

Please tick if you require the original results of this check to be sent directly to the organisation listed above


SAFE NT Form - National Police Check - REV 07/17

SECTION B - PREVIOUS RESIDENTIAL ADDRESSES

Please provide details of your previous residential addresses for the last 5 years only.


Date from: (dd/mm/yyyy) / / Date to: / / Country if outside Australia





Please attach a separate sheet if you require further space to list other previous residential addresses over the past 5 years.

SECTION C - PURPOSE OF CHECK

This section must be completed.

Police conduct a national name check. If information is obtained from other police jurisdictions, the relevant legislation or policy for that jurisdiction, together with that of the Northern Territory is applied to the information before it is released. The legislation to be applied is determined by the

Purpose / Occupation

Only one purpose per check is permitted.

Provide a brief description of the work you will be doing.

SECTION D - EMPLOYER ORGANISATION / LICENCING AUTHORITY DETAILS

Name of employer organisation/licencing authority

Postal address of organisation

Daytime Contact phone number Position title of organisation’s representative (e.g. HR Manager, Licensing Board)

Purpose is Employment Check, for appointment as an Authorised Bush�re Volunteer

Volunteer �re �ghter authorised under the Bush�res Management Act 2016



SECTION E - VOLUNTEER ORGANISATION DETAILS (this section must be completed by the volunteer organisation you will be working for)

To be eligible for the Volunteer Concession fee this section must be completed by your employer/volunteer organisation.

Name of organisation

Bush�res NT (Department of Environment and Natural Resources)Postal address of organisation

PO Box 37346

Winnellie NT 0821Daytime Contact phone number.

Please tick if you require the original results of this check to be sent directly to the volunteer organisation listed above

To be completed by CEO/Manager of Volunteer Organisation

Name/position

Signature Date signed

/ / (dd/mm/yyyy)

SECTION F - PROOF OF IDENTITY

Proof of identity documentation

current residential address, signature and date of birth. All documents must be current or valid.

Category A You must have at least ONE Category A document

1. Passport (Australian/Foreign) = 70 points

2. Australian drivers licence = 40 points

3. Firearms licence = 40 points

4. Tertiary student ID card with photo = 40 points

5. Australian evidence of age card (18+) = 40 points

6. NT Ochre card = 40 points

Category B

7. = 70 points

8. = 70 points

9. Centrelink cards = 40 points

10. Government employee ID = 40 points

11. Statutory declaration as to identity containing image of applicant = 40 points

12. Medicare card = 25 points

13. institution passbook = 25 points

14. Property rates notice/utilities notice (with current residential address) = 25 points

15. Bank statement (with current residential address) = 25 points

(Must be completed no earlier than 3 months from the date of application lodgement)

Add total points - must be 100 points or more

returned unprocessed to the postal address provided.

08 8922 0844

Collene Bremner, Executive Director



SECTION F - PROOF OF IDENTITY CONTINUED

Complete the following section with details from two of the documents used to verify your ID. You must include information from at least one Category A document from the list above, including licence/passport/ID number and expiry date.

Category A document. Please identify document number from list above (1–6).

Passport/licence/ID number

State of Issue Expiry Date / /

Country of Issue

Other document provided. Please identify document number from list above (1–15). This can be a second Category A document.

Card/licence/membership/ID number

State of Issue Expiry Date / /

Country of Issue In certain circumstances of hardship an application may be made to SAFE NT for the ability to vary the requirement for meeting 100 points. For further information contact: [email protected]

If you are under the age of 18, then one document from Group A or a statutory declaration of identity attesting that you are a current student of

SECTION G - CERTIFICATION AND STATEMENT OF CONSENT AND INDEMNITY (this section must be completed)

I certify that I am the applicant named in this form and all the details provided by me are true and correct. I have not omitted names or aliases that I have or may have used previously. I have read and understood the contents of this form.

I consent to the release of details of any convictions, or other information, including pursuant to section 15 and section 15A of the Criminal Records (Spent Convictions) Act 1992, convictions that are otherwise known as ‘spent convictions’, recorded against my name, to the person and/or organisation listed on this form.

I hereby indemnify the Northern Territory of Australia, its servants and agents including all members of Northern Territory Police against all liabilities and against all actions, suits, proceedings, claims, demands, costs, and expenses whatsoever which may be taken or made in respect of the release or use hereunder of any details of any convictions, or other information purporting to either relate to or involve me.

Name of applicant

Signature Date Signed

/ /

Payment Options (current fees are available online - www.pfes.nt.gov.au/safent)

In person to SAFE NT Ground Floor, 37 Woods Street Darwin Cash, Cheque/Money Order/Credit Card

Via Mail to SAFE NT NT Police, PO Box 39764 WINNELLIE NT 0821 Cannot accept cash through mail Cheque / Money Order Credit Card (Visa/ Mastercard)

Credit card authorisation

I authorise SAFE NT to process my payment of $ from my Visa/Mastercard.

Cardholders name

Card Number

Expiry / /

Cardholders signature

Contact: Phone: 1800 723 368 Postal: SAFE NT - PO Box 39764 WINNELLIE NT 0821 Web: www.pfes.nt.gov.au/safent Email: [email protected]

Copies of all ID must be attached to this application

Talent release authorisation

DEPARTMENT OF THE CHIEF MINISTER Page 1 of 2 27 November 2018

Permission I give permission for the Northern Territory Government to use my name and photographs, video or audio recordings of myself/my child for marketing and promotional purposes including but not limited to printed publications, newsletters, posters, advertisements, websites, social media, television commercials, billboards, and cinema and radio advertisements.

The permission will continue until I revoke permission in writing to the Northern Territory Government. In the situation where permission is revoked, every effort will be made to remove the image from future distribution; however this may not be possible or practical in some situations. This is the tal ent rel ease form tabl e. Please tab through. The tabl e is s truc tur ed such that a label cell is followed by a data entr y cell. Overtype yes /no fiel ds with your answer. Items marked with a # are for of fice use onl y.

I have read and understand the above: Yes/No

Name:

Guardian name: if under 18 years:

Phone:

Email:

Do you identify as being of Aboriginal or Torres Strait Islander descent? (Wherever possible, the Northern Territory Government will remain sensitive to cultural, family and personal sensitivities. This information is optional and will not be used for any purpose involving discrimination.)

Yes/No

Signature: (if under 18 years of age, must be signed by parent/guardian)

Date: dd/mm/yyyy

Notes or special considerations:

Office use # Collected on behalf of the Northern Territory Government* # Name: #

Organisation: #

Email/phone: #

Description of job and person:# (i.e. region, location, event name, clothing, hair colour, gender, position in shot)

Notes: # (sensitivities, exclusions, copyright considerations, original image number, file name)

end of for m

Talent release authorisation

DEPARTMENT OF THE CHIEF MINISTER 27 November 2018

Page 2 of 2

Talent – information sheet The Northern Territory Government (NTG) is collecting your information to obtain permission to use photos, video and/or audio recordings of you in Northern Territory Government advertising, documents, promotional materials, websites and social media accounts. Photos, video (now referred to as images) and/or audio recordings or other personal information described in this form may be supplied to NTG staff, contractors or service providers (i.e. graphic designers) engaged by the Northern Territory Government to produce these materials, but will not be provided to any other person or organisation for purposes other than described. The images or audio recording and a copy of the talent release form may also be stored on the NT Government Image Library.

Before you agree to any images or audio recordings of you being used by the Northern Territory Government, there are some important things you need to know.

What will happen to my images once they are taken? The Northern Territory Government will store your images digitally in its photographic library database. The talent release form that you signed will be filed with your images. Once stored in the database, your images may be used by any Northern Territory Government department or agency for a wide variety of purposes, ongoing, until advised otherwise by you in writing.

Who can use my images? Your images cannot be shared with any person, organisation or company outside of the Northern Territory Government, other than those specified, without your express permission. This includes private companies, political parties, and charitable organisations. Images may be shared with a Minister’s office in relation to a project, initiative and/or awareness messaging.

Where will my images or audio be used? Your images may be used in a variety of applications. Some of the typical places could include printed brochures and flyers, newspaper advertising, magazines and journals, television commercials, radio commercials, government events and displays, newsletters, websites and social media channels, outdoor billboards and banners, bus advertising and others as required. Your image may be used in situations that are unrelated to the original purpose for which they were taken.

What if I don’t want my photograph to be used somewhere? It can be quite a surprise to see your photograph blown up two metres tall at a display, or to suddenly find yourself appearing on television. You need to be aware that your photograph may be used in these situations unless you ask for it not to be. If there are circumstances where you do not want your photo used, make sure you write that down on the Talent Release Form you sign.

I had my photograph taken but I no longer want it used. How can I get it taken off the database? You should telephone the number on this form or send an email to let us know.

Why do you need to know if I identify as being of Aboriginal or Torres Strait Islander decent? The NT Government delivers a wide range of services and public information programs specifically designed to reach Territorians who identify as being of Aboriginal or Torres Strait Islander descent and we appreciate that there may be certain cultural sensitivities about using your image.

You are entitled to access and amend the information provided by you. For more information or to update your records please contact:

Northern Territory Government, Department of Environment and Natural ResourcesBushfires NTPO Box 37346, Winnellie NT 0821Phone: 08 89220844Email: [email protected]

appointment - authorised bushfire volunteer...discuss the matter with my brigade captain and...

Documents