Staffing – Prohibition Notice Declaration Employment

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Prohibition notice declaration for prospective staff members


  • The declaration may be completed by any prospective staff member seeking employment or engagement with an education and care service
  • This form is designed to support approved providers to ensure they do not engage or employ a person who is prohibited from working in an education and care service, in line with Section 188 of the Education and Care Services National Law
  • Completed forms should be retained and stored by the approved provider to support compliance with Section 188 of the Education and Care Services National Law
  • Please note this form does not need to be lodged with the regulatory authority

Part A: Personal details

1.        Please complete the following:

Title:                                                                 

Last name:                                                         

First name:                                                     

Mobile number:                                                                                                                                                                                   

Phone number:                                                 

Date of birth: DD/MM/YYYY            /          /                                                                                                                                                            

Email:                                                                                                                                                      

Address:                                                                                                                                               

Suburb/Town:                                                                                                                                      

State/Territory:                                        

Postcode:                                                          

2.        Please provide details of any former names or other names you may be known by:                                                                                                                                                                                              

3.        Are you currently subject to a prohibition notice under the Education and Care Services National Law?        Yes         No

Please note that under section 187 of the Education and Care Services National Law, a person who is subject to a prohibition notice is not allowed to work for or be engaged by an education and care service or carry out any other related activity.

4.        Are you currently prohibited or restricted from working with children under any other law?        Yes         No

Part B: Declaration 

I,                                                                         [insert full name of person signing the declaration] declare that:

  1. the information provided on this form is true, complete and correct
  2. the approved provider or a representative of the approved provider is authorised to verify any information provided in this form
  3. I am aware that under the Education and Care Services National Law penalties apply if false or misleading information is

Signature of person making the declaration:                                                                                                           

Signed at:                                                  on the                                                 

                             [place]                                                        [date]

Signature of witness:                                                           Name of witness:                                                       

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