Replacement MSIC Form (Issuing Body Use Only)

Transcription

Application Identification NumberReplacement MSIC FormFor Replacement of MSIC Lost (or Not Distributed as Intended), Damaged, Stolen orChange of Type(Issuing Body Use Only)MSIC Conditions of Use:You must keep your MSIC in a safe and secure location whilst not in use. You must not alter or deface your MSIC. Your MSIC is nottransferable and can only be used by you.You must return your blue MSIC within 30 days to the issuing body when: it expires; it is cancelled; it has been damaged, altered or defaced; or you no longer have an operational needIf your MSIC is lost or stolen, you will need to provide a statutory declaration or police report or other information issued by the policebefore a replacement card can be issued by an issuing body.You will have committed an offence if your MSIC is lost, stolen or destroyed and you do not advise your issuing body within 7 days.Form Instructions:Please complete this form starting at Part A. Once all information is completed, you may email the forms to us at msic@veritasgroup.com.auor post it to us at PO Box 7696, Cloisters Square WA 6850 with any supporting documents.Please Note: Lodgement of this form is not supported by Australia Post.Part A: Applicant InformationPersonal DetailsSurname:Given Names:Date of Birth (DD/MM/YY):Contact Details/ /Home Phone:Work Phone:Mobile:Email:All other surnames used (Tick name used to apply for MSIC)Previous MSIC Number (if known) or Issuing BodyFormer Surname(s):MSIC Number (e.g. VEP0012345):Issuing Body (e.g. Veritas Engineering):Tick Delivery Option:Pick up from Veritas’ Perth CBD officeSend to Postal Address (Registered Post)Home AddressPostal Address (if applicable, write ‘same as ode:Suburb:State:Country:Postcode:Part B: DeclarationDeclaration: The information that I have given in, or in connection with, this form is true and correct.Printed Name:Signed:v4.1Date:www.msic.net.auVeritas Engineering Pty Ltd

Application Identification NumberReplacement MSIC FormFor Replacement of MSIC Lost (or Not Distributed as Intended), Damaged, Stolen orChange of Type(Issuing Body Use Only)Part C: Lost, Damaged, Stolen or Change of TypePlease provide answers to the following questions:a) Have you lost your MSIC (or MSIC not distributed as intended)?If you ticked ‘Yes’ to (a) above, you will need to: provide a statutory declaration setting out the circumstances of the loss or destruction of the MSIC; andowith this declaration, provide a statement that since your background check was completed,whether or not you have been convicted of an maritime-security relevant offence confirm you have an operational need for the replacement MSICb) Has your MSIC been damaged, defaced, or altered?If you ticked ‘Yes’ to (b) above, you will need to: provide a statutory declaration setting out the circumstances of the loss or destruction of the MSIC; andowith this declaration, a provide statement that since your background check was completed,whether or not you have been convicted of an maritime-security relevant offence confirm you have an operational need for the replacement MSICc) Has your MSIC been stolen?If you ticked ‘Yes’ to (c) above, you will need to: provide a copy of a police report or other information issued by the police regarding the theft provide a statutory declaration stating that since your background check was completed, whether or notyou have been convicted of an maritime-security relevant offence confirm you have an operational need for the replacement MSICYesNoYesNoYesNoHave you attached a copy of the police report?YesNod) Do you need to change your type of MSIC (e.g. get a replacement blue MSIC in substitution for a white MSIC, orvice versa)?If you ticked ‘Yes’ to (d) above, you will need to: confirm you have an operational need for the replacement MSIC provide a statutory declaration stating that since your background check was completed, whether or not youhave been convicted of an maritime-security relevant offenceYesNoPart D: Sponsoring OrganisationTAX INVOICEVeritas Engineering Pty Ltd ABN 57 107 945 988If your employer has established an account with Veritas Engineering and has agreed to pay for your replacement MSIC, please list thatorganisation here. Processing shall not commence until verified:Sponsoring Organisation:Business Unit (if applicable):Part E: Payment DetailsTotal Amount Payable for Replacement MSIC: 121.00 (includes GST of 11.00)Submit this form and supporting documentation using one of the options listed below. If your employer requires you to make payment foryour MSIC, payment options are also listed. The date signed by the interviewer on the reverse side of this form constitutes the date of formacceptance.Email completed application to:msic@veritasgroup.com.auORPost to:PO BOX 7696, Cloisters Square WA 6850For payment by credit card (VISA, MasterCard, AMEX*):Credit Card Number:- - -Expiry: /Amount:CVV : (3 digit for VISA/MC or 4 digit for AMEX)Name on card:Signature:* Credit Card Fees: Visa/MasterCard/AMEX 1.5%Part F: Card Issue (Issuing Body Use Only)Authorisation to issue (Issuing Body Rep.)Signed:Collected by ic.net.auVeritas Engineering Pty Ltd

Commonwealth of AustraliaSTATUTORY DECLARATIONStatutory Declarations Act 19591 Insert the name,address andoccupation ofperson makingthe declarationI,1make the following declaration under the Statutory Declarations Act 1959:2 Set out matterdeclared to innumberedparagraphs2Since my background check was completed, I have not been convicted of a maritime-securityrelevant offence.I understand that a person who intentionally makes a false statement in a statutory declaration isguilty of an offence under section 11 of the Statutory Declarations Act 1959, and I believe that thestatements in this declaration are true in every particular.3 Signature ofperson makingthe declaration34 Place5 Day6 Month and yearDeclared at7 Signature ofperson beforewhom thedeclaration ismade (see over)78 Full name,qualification andaddress of personbefore whom thedeclaration ismade (in printedletters)84on5of6Before me,Note 1 A person who intentionally makes a false statement in a statutory declaration is guilty of an offence, the punishment forwhich is imprisonment for a term of 4 years — see section 11 of the Statutory Declarations Act 1959.Note 2 Chapter 2 of the Criminal Code applies to all offences against the Statutory Declarations Act 1959 — see section 5A ofthe 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:ChiropractorDentistLegal practitionerMedical practitionerNurseOptometristPatent attorneyPharmacistPhysiotherapistPsychologistTrade marks attorneyVeterinary 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:Agent of the Australian Postal Corporation who is in charge of an office supplying postal services to the publicAustralian Consular Officer or Australian Diplomatic Officer (within the meaning of the Consular Fees Act 1955)BailiffBank officer with 5 or more continuous years of serviceBuilding society officer with 5 or more years of continuous serviceChief executive officer of a Commonwealth courtClerk of a courtCommissioner for AffidavitsCommissioner for DeclarationsCredit union officer with 5 or more years of continuous serviceEmployee of the Australian Trade 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 his or her function in that placeEmployee of the Commonwealth who is:(a) in a country or place outside Australia; and(b) authorised under paragraph 3 (c) of the Consular Fees Act 1955; and(c) exercising his or her function in that placeFellow of the National Tax Accountants’ AssociationFinance company officer with 5 or more years of continuous serviceHolder of a statutory office not specified in another item in this listJudge of a courtJustice of the PeaceMagistrateMarriage celebrant registered under Subdivision C of Division 1 of Part IV of the Marriage Act 1961Master of a courtMember of Chartered Secretaries AustraliaMember of Engineers Australia, other than at the grade of studentMember of the Association of Taxation and Management AccountantsMember of the Australasian Institute of Mining and MetallurgyMember of the Australian Defence Force who is:(a) an officer; or(b) a non-commissioned officer within the meaning of the Defence Force Discipline Act 1982 with 5 or more years of continuous service; or(c) a warrant officer within the meaning of that ActMember of the Institute of Chartered Accountants in Australia, the Australian Society of Certified Practising Accountants or the National Institute ofAccountantsMember of:(a) the Parliament of the Commonwealth; or(b) the Parliament of a State; or(c) a Territory legislature; or(d) a local government authority of a State or TerritoryMinister of religion registered under Subdivision A of Division 1 of Part IV of the Marriage Act 1961Notary publicPermanent employee of the Australian Postal Corporation with 5 or more years of continuous service who is employed in an office supplying postalservices to the publicPermanent employee of:(a) the Commonwealth or a Commonwealth authority; or(b) a State or Territory or a State or Territory authority; or(c) a local government authority;with 5 or more years of continuous service who is not specified in another item in this listPerson before whom a statutory declaration may be made under the law of the State or Territory in which the declaration is madePolice officerRegistrar, or Deputy Registrar, of a courtSenior Executive Service employee of:(a) the Commonwealth or a Commonwealth authority; or(b) a State or Territory or a State or Territory authoritySheriffSheriff’s officerTeacher employed on a full-time basis at a school or tertiary education institution

Statement of Operational Need for aMaritime Security Identification Card (MSIC)Application Identification NumberEmployers may complete this letter on behalf of their employees, contractors, or other authorised persons to serve asdocumentary evidence of the listed applicants' Operational Need to possess either a blue MSIC or white MSIC.I acknowledge that a person has an Operational Need to hold a blue MSIC if his or her occupation or business interests require, or willrequire, him or her to have unmonitored access to a maritime security zone at least once each year (in accordance with the MaritimeTransport and Offshore Facilities Security Regulations 2003, Section 6.07F(1)).I acknowledge that a person has a has an operational need to hold a white MSIC if the person is required to be directly involved inthe issue of MSICs for an issuing body (in accordance with the Maritime Transport and Offshore Facilities Security Regulations 2003,Section 6.07F(2), 6.07B(1)).I confirm that the following individual possesses an Operational Need for the type of MSIC selected:Full NameWhat activities/duties do you perform?MSIC TypeMSIC ExpiryBlue MSIC2 yearsWhite MSIC4 years (not applicable for White MSICs)Applicant to selectThe above named individual also understand that it is an offence to retain their MSIC if they no longer possess an OperationalNeed for it (i.e. MSIC must be returned to the Issuing Body within 30 days if their operational need no longer exists as per Section6.08Q of the Regulations).Payment DetailsApplicant to payCompany to pay. Business unit / project (if applicable)Purchase order number or cost ss:Contact Number:Email:Employee Extra DetailsUnmonitored Access FrequencyWhat is your occupation and/or what activities/duties do you undertake which requirefrequent access to a maritime security zone?Last Revised: 18 December 2018

before a replacement card can be issued by an issuing body. You will have committed an offence if your MSIC is lost, stolen or destroyed and you do not advise your issuing body within 7 days. Form Instructions: Please complete this form starting at Part A. Once all information is completed,