Consent to criminal history record check

Complete your Consent to criminal history record checkThis link will download a file (NAT 16358, 234KB) in Portable Document Format (PDF).

When to use this application

You only need to complete this form if you have received a request from us to do so. We will ask you to complete this form if you:

  • are applying for an excise licence
  • will participate in the management or control of the premises specified in an excise licence application
  • are a director, officer or shareholder of a company applying for an excise licence (or already holds an excise licence) and you participate in the management or control of that company.

We may also ask you to complete this form if you are an associate of a licence applicant (within the meaning of the Income Tax Assessment Act 1997)

For more information about this form contact the Excise Licensing Group.


Completing your form

  • Answer all questions.
  • Place X in ALL applicable boxes.
  • If you need help, contact the Excise Licensing Group.

Section A: Consent form details

Provide the name of the licence applicant (or licence holder) and their Australian business number (ABN).

Section B – Your details

Provide the personal details requested including residential addresses for the last five years. You need to provide street addresses, not post office boxes or other address types.

Section C – Criminal charges or convictions

Complete questions 1 and 2 after carefully reading the following important information.

We use this form to obtain information to assess a person's suitability for an excise licence. Under excise law, we may only obtain information from other people, agencies or organisations with your written consent. You do not have to provide your consent, however without it we may be unable to grant an excise licence.

Criminal history record check

Criminal history record checks are an essential part of assessing a person’s suitability for an excise licence. If you have a record, it will not automatically affect our decision – we consider each case on its merits. It is important that you provide full details when completing this form.

If you give written consent, we will arrange a criminal record check. We may do this directly through the relevant Australian police services, other law enforcement agencies, or through the Australian Criminal Intelligence Commission acting on our behalf.

If you complete and sign this form, you are giving consent to these agencies to:

  • access their records of your criminal history (if any)
  • disclose information contained in those records to us.

Spent convictions

You don't have to disclose any spent convictions to us. This is because both:

  • you are not required by law to disclose to any person (including us) any convictions that have been pardoned, quashed or ‘spent’ unless an exclusion applies
  • no exclusions apply for the purpose of applying for an excise licence.

For excise purposes:

  • a pardon means a free and absolute pardon that has been granted to a person because he/she was wrongly convicted of a Commonwealth, state or territory offence
  • a quashed conviction is a Commonwealth, state or territory conviction that has been set aside by a court
  • a spent conviction is a conviction of either a Commonwealth, state or territory that satisfies all of the following conditions    
    • it is 10 years since the date of the conviction (or five years for juvenile offenders)
    • the individual was not sentenced to imprisonment or was not sentenced to imprisonment for more than 30 months
    • the individual has not re-offended during the 10 or five year waiting period
    • no other exclusion applies.

Section D – Declaration

You must declare all the information you have provided in this form is correct.

If we subsequently discover that you provided false or misleading information, we may not grant an excise licence.

Before you lodge your form

The Australian Criminal Intelligence Commission requires us to establish your identity. To do that, you need to provide certified copies of documents from the list below.

If the documents you provide are in a previous name, you need to provide a document that shows how your name was changed (for example, marriage certificate, deed poll or change of name certificate).

For original documents in a language other than English, you'll need to provide a written translation certified by a government or professional translation service.

You should provide one Category A document and sufficient Category B documents to achieve 100 points. Category B documents marked with an asterisk (*) can only be used once from the same source (for example you cannot provide two gas bills from the same supplier but for different periods).

Category A documents

  • Australian full birth certificate – cannot be an extract (70 points)
  • Australian citizenship certificate/Extract from Register of Citizen by Descent (70 points)
  • Australian passport (70 points)
  • Overseas passport with evidence of Australian immigration status (70 points).

Category B documents

  • Australian driver’s licence with your photo and signature and current address that matches the details provided on the consent form (40 points)
  • Permit – government issued (40 points)
  • Tertiary student identification card with your photo and signature issued from an Australian government accredited education authority (40 points)
  • Social security/pension card (40 points)
  • Mortgage/security documents over property* (35 points)
  • Medicare card* (25 points)
  • Credit, debit, ATM cards – several may be submitted but only one per financial institution (25 points)
  • Utility bill/registration notice, for example electricity, gas, telephone, water* (25 points)
  • Rates notice, for example council* (25 points)
  • Membership card, for example union, professional/trade association, library* (25 points)
  • Certificate of title* (25 points)
  • Adoption or marriage certificate* (25 points)
  • Public employment identity card (25 points).

Your copies of the above documents must contain the following declaration on each page, completed and signed by the certifier:

"I have compared this copy with the original document and declare that it is a true and correct copy"

  • Signature of certifier
  • Date
  • Name of certifier
  • ID number if applicable
  • Contact details of certifier.

Approved certifiers include:

  • Bail justice
  • Barrister
  • Commissioner for Affidavits
  • Commissioner for Declarations
  • Commissioner for Oaths
  • Doctor
  • Judge
  • Justice of the Peace
  • Minister of religion (who is authorised to celebrate marriages)
  • Police officer (rank of sergeant or above, or highest ranking officer in the station)
  • Proclaimed bank manager
  • Sherriff
  • Solicitor.

For more information about the documents you need to establish your identity, contact the Excise Licensing Group.


For information about your privacy refer to the full privacy statement at

Last modified: 02 Sep 2016QC 19113