Statutory Declaration by a Prostitute - Department of Business

(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