Full Place of Birth- Full Name of Parents as recorded on your Birth Certificate Father’s Surname- Father’s Given Names- Mother’s Surname- Mother’s Maiden Surname- Mother’s Given Names- Your Current Residential Address- Do you wish to have your Northern Territory Yes No certificate noted with the new name? PRIVACY STATEMENT The Office of Births, Deaths & Marriages is collecting the information on a change of name form so that it can determine your eligibility to register the requested change of name and to prevent fraud. If all the information requested is not completed then the change of name may not be registered. The collection of the information is required by the Northern Territory Births, Deaths & Marriages Registration Act. The information is recorded and preserved in the Register of Changes of Name and in appropriate cases, may be accessed by government agencies, private organisations and members of the public in accordance with the Access Policy issued under the Act. Failure to provide the information may result in incomplete registration entries and the of certificates. Your personal information provided in this form can be accessed by you on request. If you have any queries, please contact the Deputy Registrar on (08) 8999 6119. Please Note: complete all sections below and print clearly in BLOCK LETTERS. Whiteout is not to be used on this form so please ensure that any corrections made are crossed out and initialled. Self-Disclosure of Offender Reporting & Criminal History Child Protection Offender Reporting Do you have any registration and reporting obligations under the NT Child Protection (Offender Reporting and Registration) Act or a corresponding Act from another jurisdiction? YES NO National Police Check All applications received for a change of name in the Northern Territory are subject to a National Police Check with NT Police. We require your permission to perform this check and it will be at no extra cost. If you choose not to give us permission then we may ask you to provide a recent National Police Check at your own cost and this may delay your application. Do you consent to Births, Deaths and Marriages applying for a National Police Check with NT Police on your behalf? YES There is no cost involved. NO We may ask you to provide a current National Police Check from NT Police. Criminal History
Full Place of Birth- Full Name of Parents as recorded on your Birth Certificate Father’s Surname- Father’s Given Names- Mother’s Surname- Mother’s Maiden Surname- Mother’s Given Names- Your Current Residential Address- Do you wish to have your Northern Territory certificate noted with the new name? Yes No PRIVACY STATEMENT The Office of Births, Deaths & Marriages is collecting the information on a change of name form so that it can determine your eligibility to register the requested change of name and to prevent fraud. If all the information requested is not completed then the change of name may not be registered. The collection of the information is required by the Northern Territory Births, Deaths & Marriages Registration Act. The information is recorded and preserved in the Register of Changes of Name and in appropriate cases, may be accessed by government agencies, private organisations and members of the public in accordance with the Access Policy issued under the Act. Failure to provide the information may result in incomplete registration entries and the of certificates. Your personal information provided in this form can be accessed by you on request. If you have any queries, please contact the Deputy Registrar on (08) 8999 6119. Please Note: complete all sections below and print clearly in BLOCK LETTERS. Whiteout is not to be used on this form so please ensure that any corrections made are crossed out and initialled. Self-Disclosure of Offender Reporting & Criminal History Child Protection Offender Reporting Do you have any registration and reporting obligations under the NT Child Protection (Offender Reporting and Registration) Act or a corresponding Act from another jurisdiction? YES NO National Police Check All applications received for a change of name in the Northern Territory are subject to a National Police Check with NT Police. We require your permission to perform this check and it will be at no extra cost. If you choose not to give us permission then we may ask you to provide a recent National Police Check at your own cost and this may delay your application. Do you consent to Births, Deaths and Marriages applying for a National Police Check with NT Police on your behalf? YES There is no cost involved. NO We may ask you to provide a current National Police Check from NT Police. Criminal History