Statutory Declaration by a Prostitute - Department of Business

Northern Territory of AustraliaProstitution Regulation ActSection 9(2)Statutory Declaration by a Prostitute(1)Insert full name(2)Residential addressI, (1)of (2)previously resident atdo solemnly and sincere declare as follows:(3)If you do not haveone of these typesof name (e.g. youare not married)please write “notapplicable” in theappropriate blankspacea) My maiden name is (3)My married name is (3)My working name is (3)My alias or work name is (3)b) My date of birth is(4)Write down thetown, the State orTerritory and thecountry in whichyou were bornc) I was born in (4)d) Physical description:i. I am cm tallii. I weighKg(5)E.g. black, fair, oliveiii. My complexion is (5)iv. The colour of my eyes arev. My natural hair colour isMy present hair colour is(6)E.g. any tattoos orscars you may haveand where they areon your body(7)Delete as applicablevi. I have the following distinguishing features (6)e) I (7) have / have not been convicted in the last 10 years ofcommitting a serious drug offence or a violent offence, asthose offences are defined in section 9(11) of the ProstitutionRegulation Act, or of attempting to commit such an offence.form_escort_stat_dec V2

(8a)Describe theoffence. Use anydocuments youhave from theCourt, or, if you donot have anydocuments, brieflydescribe theincident, e.g. I hitsomeone(8b)Write the name ofthe Court e.g. LocalCourt, MagistratesCourt, SupremeCourt and the townor city that courtwas in e.g. Darwin,Sydney(8c)Write down thetown or city and theState or Territorywhere the offencetook place (e.g.Tennant Creek)(9)Write down thename and addressof any escortagencies you haveworked for, whetherin the NT orelsewhere(10)Write down thename, address, andtelephone numberof the escort agencyor agencies youintend to work for inthe NT(11)Town or city youhave signed thisform e.g. AliceSpringsf) If you have been convicted of an offence referred to it item(e), complete the following (8):i. Date of convictionOffence (8a)Court (8b,c)ii. Date of convictionOffence (8a)Court (8b,c)g) I have provided prostitution services on behalf of the followingagencies (9)h) I intend to work as a prostitute for the following agencies (10)and I make this solemn declaration by virtue of the provisions ofthe Oaths, Affidavits and Declarations Act and solemnly andsincerely declare that all statements and information contained inthis declaration are true and correct to the best of my knowledge.SignatureDeclared at(11)on the day of 20(12)Witness’ full name,address andtelephone numberbefore me(12)Signature of WitnessNote:(1) Witness must be someone who is over 18 years of age.(2) A person wilfully making a false statement in a statutory declaration isliable to a fine or imprisonment.(3) The applicant is required to attend and present this application to thefront counter of a local Police Station along with the Application forCertificate that Prostitute is Free of a Finding of Guilt for CertainOffences form and an Authority to Release Criminal History form.form_escort_stat_dec V2

Notice In Accordance with the Information Act(Information Privacy Principle 1)Gambling and Licensing Services (GLS – a division of NT Department of Business) isseeking information from you for the purposes of your application.Information Privacy Principle 1 (IPP 1) requires that a public sector organisation mustnot collect personal information unless the information is necessary for one or moreof its functions or activities. If personal information about an individual is collectedfrom the individual, the organisation must take reasonable steps to ensure that theindividual is aware of certain matters. For the purposes of IPP 1, the following adviceis provided.a) You are able to access your personal information that you have provided bymaking a written request to the Director of Licensing.b) The information is required pursuant to the Prostitution Regulation Act. TheAct requires that certain matters must be considered when deciding whetheror not to approve an application.c) The information will be kept confidential except as follows:i) Information may be sought from Police, government agencies,interstate licensing authorities, or referees or other persons nominatedby you. Information may be released to those sources to the extentnecessary to verify information about you and your application.ii) If a hearing is involved, information will be released to the parties,Commission or the Court, as required by the Act.iii) Registers of licences and permits will be maintained and may bemade available to the public on request.d) You do not have to provide information if you do not wish to do so. However,an application may not be approved if there is insufficient information toproperly determine the matter in accordance with the Act.Website: http://www.nt.gov.au/glsTerritory Business Centres - Toll free: 1800 193 111, e: territory.businesscentre@nt.gov.auDarwinGround Floor, DevelopmentHouse76 The EsplanadeDarwinGPO Box 9800Darwin NT 0801t: (08) 8982 1700f: (08) 8982 1725KatherineShop 1, Randazzo Building18 Katherine TerraceKatherinePO Box 9800Katherine NT 0851t: (08) 8973 8180f: (08) 8973 8188Tennant CreekShop 2, Barkley HouseCnr Davidson andPaterson StreetTennant CreekPO Box 9800Tennant Creek NT 0861t: (08) 8962 4411f: (08) 8982 1725Alice SpringsGround Floor, The GreenWell Building50 Bath StreetAlice SpringsPO Box 9800Alice Springs NT 0871t: (08) 8951 8524f: (08) 8951 8533General Disclaimer: The material contained in this publication is intended for use as a guide and forgeneral information only. It is not intended to be a substitute for independent professional advice. TheNorthern Territory Department of Business accepts no responsibility or liability for the correctness,accuracy and completeness of any of the material contained in this publication and recommends thatusers of this publication exercise their own skill, care and judgment in the application of the informationcontained in the publication.form_escort_stat_dec V2