(2) Here insert the matter declared to, solemnly and sincerely declare (2) either directly following the word or, if the matter is lengthy, ‘declare’ That I have not been charged, summonsed or convicted of any offence my insert the words follows’ and ‘äs thereafter set out the matter in last criminal history check for my tobacco licence and I am not the subject of numbered paragraphs any pending charges for any offence. This declaration is true and I know it is an offence to make a statutory declaration knowing it is false in a material particular. Declared at: ________________________________________________________ On day of 20_____ the_______________ _______________ (3) (3) Signature of the person making the declaration Witnessed by: (4) Signature of the person before whom (4) the declaration is made (5) (5) Here insert full name of person before whom the declaration is made, legibly written, typed or stamped (6) (6) Here insert contact address or telephone number of person before whom the declaration is made Note: This declaration may be witnessed by any person who is at 18 (eighteen) years of age. Note: This written statutory declaration must comply with Part 4 of the Oaths Affidavits and Declarations Act. Note: Making a declaration knowing it is false in a material particular is an offence for which you may be fined or imprisoned. Fees and Payment Contact your Territory Business Centre for the relevant schedule of fees. Cash Territory Business Centre – Cheque - payable to Receiver of Territory Monies (RTM) Credit card Visa MasterCard Name on Card Credit Card Number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
(2) Here insert the matter declared to, either directly following the word ‘declare’ or, if the matter is lengthy, insert the words ‘äs follows’ and thereafter set out the matter in numbered paragraphs solemnly and sincerely declare (2) That I have not been charged, summonsed or convicted of any offence my last criminal history check for my tobacco licence and I am not the subject of any pending charges for any offence. This declaration is true and I know it is an offence to make a statutory declaration knowing it is false in a material particular. Declared at: ________________________________________________________ On the_______________ day of _______________ 20_____ (3) Signature of the person making the declaration (3) (4) Signature of the person before whom the declaration is made Witnessed by: (4) (5) Here insert full name of person before whom the declaration is made, legibly written, typed or stamped (5) (6) Here insert contact address or telephone number of person before whom the declaration is made (6) Note: This declaration may be witnessed by any person who is at 18 (eighteen) years of age. Note: This written statutory declaration must comply with Part 4 of the Oaths Affidavits and Declarations Act. Note: Making a declaration knowing it is false in a material particular is an offence for which you may be fined or imprisoned. Fees and Payment Contact your Territory Business Centre for the relevant schedule of fees. Cash – Territory Business Centre Cheque - payable to Receiver of Territory Monies (RTM) Credit card Visa MasterCard Name on Card Credit Card Number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _