FORM Application for Adult Membership A1 Jul 2017 INSTRUCTIONS The Applicant will complete all of this form, including the declarations and consents and forward to the Group Leader/Leader-In-Charge. The Group Leader/Leader-In-Charge will sign and endorse the form with the details of the desired appointment and level of participation that the applicant may have before appointment, and send to their Supervising Commissioner, who will sign and forward it to the Region Office. PLEASE WRITE CLEARLY PERSONAL DETAILS Title Family Name (e.g. Dr, Mr, Mrs) First Given Name Other Given Names M F Date of Birth City/Town of Birth Country of Birth Nationality Preferred First Name Maiden or Former Names (if any) (if different to First Given Name) Partner's Name Marital Status Religion / Denomination (optional) Address Town/Suburb State Postcode ( ) ( ) ( ) Home Phone Mobile Work Phone Email 1 Email 2 Postal Address (if different) Address Town/Suburb State Postcode Occupation Skills/Hobbies BLOCK LETTERS PLEASE PREVIOUS SERVICE AS A MEMBER OF THE SCOUT MOVEMENT INCLUDING INVOLVEMENT WITH SCOUTS AUSTRALIA NSW, INTERSTATE SERVICE AND/OR OVERSEAS SERVICE Please attach a copy of your interstate or overseas service and training history Previous Membership No. (if known) State/Country Appointment Formation Dates (From - To) WORKING WITH CHILDREN CHECK Please provide your current Working With Children Check Number. Working With Children Check Number Expiry Date Note: The above WWCC status will be verified by Scouts online. REGION USE ONLY Name of Assigned Personal Leader Advisor RECORD OF REFEREES CHECK CONTACTED BY (Print Full Name) DATE APPLICATION SUPPORTED Name 1: Yes No Name 2: Yes No COMPLETED REFERENCE CHECK DOCUMENTS MUST BE ATTACHED TO THIS A1 Reference Check Document for Name 1 Attached Reference Check Document for Name 2 Attached ( ) ( ) STATE OFFICE USE ONLY Membership No. Police Clearance Date WWCC Verified Date P O Box 125 Ph: 02 9735 9000 Level 1, Quad 3, Scouts Australia Lidcombe, NSW Fax: 02 9735 9001 102 Bennelong Parkway, NSW Sydney Olympic Park, NSW 2127 1825 E-mail: info@nsw.scouts.com.au APPLICANT:
Application for Adult Membership FORM A1 Jul 2017 INSTRUCTIONS The Applicant will complete all of this form, including the declarations and consents and forward to the Group Leader/Leader-In-Charge. The Group Leader/Leader-In-Charge will sign and endorse the form with the details of the desired appointment and level of participation that the applicant may have before appointment, and send to their Supervising Commissioner, who will sign and forward it to the Region Office. PLEASE WRITE CLEARLY PERSONAL DETAILS Title (e.g. Dr, Mr, Mrs) Family Name First Given Name Other Given Names M F Date of Birth City/Town of Birth Country of Birth Nationality Preferred First Name (if different to First Given Name) Maiden or Former Names (if any) Marital Status Partner's Name (optional) Religion / Denomination Address Town/Suburb State Postcode Home Phone ( ) Mobile ( ) Work Phone ( ) Email 1 Email 2 Postal Address (if different) Address Town/Suburb State Postcode Occupation Skills/Hobbies BLOCK LETTERS PLEASE PREVIOUS SERVICE AS A MEMBER OF THE SCOUT MOVEMENT INCLUDING INVOLVEMENT WITH SCOUTS AUSTRALIA NSW, INTERSTATE SERVICE AND/OR OVERSEAS SERVICE Please attach a copy of your interstate or overseas service and training history Previous Membership No. (if known) State/Country Appointment Formation Dates (From - To) WORKING WITH CHILDREN CHECK Please provide your current Working With Children Check Number. Working With Children Check Number Expiry Date Note: The above WWCC status will be verified by Scouts online. REGION USE ONLY Name of Assigned Personal Leader Advisor RECORD OF REFEREES CHECK CONTACTED BY (Print Full Name) DATE APPLICATION SUPPORTED Name 1: Yes No Name 2: Yes No COMPLETED REFERENCE CHECK DOCUMENTS MUST BE ATTACHED TO THIS A1 Reference Check Document for Name 1 Attached ( ) Reference Check Document for Name 2 Attached ( ) STATE OFFICE USE ONLY Police Clearance Date WWCC Verified Date Membership No. Scouts Australia NSW Level 1, Quad 3, 102 Bennelong Parkway, Sydney Olympic Park, NSW 2127 P O Box 125 Lidcombe, NSW 1825 Ph: 02 9735 9000 Fax: 02 9735 9001 E-mail: info@nsw.scouts.com.au APPLICANT:
A1-Application-for-Adult-Membership-Jul-17.docx