Application for eligibility declaration (Form 10-10)

Important Information

This form is not to be used as a Yellow Card or Yellow Card Exemption application form.

The Disability Services Act 2006 identifies some disqualifying offences, which automatically preclude a person from being issued with a positive notice. If a conviction for one of the disqualifying offences appears in a person's criminal history, or if the person is subject to certain offender reporting or prohibition orders, the person is known as a disqualified person.

It is an offence for a disqualified person to apply for a prescribed notice.

Please see the fact sheet Who is a disqualified person (PDF, 426 KB) Who is a disqualified person (DOCX, 89 KB) for further information, including a complete list of disqualifying offences. 

Purpose

For use by a disqualified person seeking to be declared eligible to apply for a prescribed notice.

Checklist

  1. Check that your details are correct
  2. Complete the declaration
  3. Complete the payment details section (Part E)
  4. If payment is by credit card, please pay online via:
    Make a Yellow Card Application payment
  5. Ensure all signatures are on the form
  6. Have your identification documents certified by a Justice of the Peace

Submitting your request

Further information

If you have any questions please email Criminal History Screening or phone the criminal history screening hotline: 1800 183 690.