Application Identification Number Replacement MSIC: Lost, Damaged, Stolen or Change of Type Form (Issuing Body Use Only) MSIC Conditions of Use: You must keep your MSIC in a safe and secure location whilst not in use. You must not alter or deface your MSIC. Your MSIC is not transferable and can only be used by you. You must return your blue MSIC within 30 days to the issuing body when: it expires; it is cancelled; it has been damaged, altered or defaced; or you no longer have an operational need If your MSIC is lost or stolen, you will need to provide a statutory declaration or police report or other information issued by the police before a replacement card can be issued by an issuing body. You will have committed an offence if your MSIC is lost, stolen or destroyed and you do not advise your issuing body within 7 days. Form Instructions: Please complete this form starting at Part A. Once all information is completed, you may email the forms to us at msic@veritasgroup.com.au or post it to us at PO Box 7696, Cloisters Square WA 6850 with any supporting documents. Please te: Lodgement of this form is not supported by Australia Post. Part A: Applicant Information Personal Details Surname: Given Names: Contact Details Home Phone: Work Phone: Date of Birth (DD/MM/YY): / / Mobile: Email: All other surnames used (Tick name used to apply for MSIC) Previous MSIC Number (if known) or Issuing Body Former Surname(s): MSIC Number (e.g. VEP0012345): Issuing Body (e.g. Veritas Engineering): Tick Delivery Option: Pick up from Veritas Perth CBD office Send to Postal Address (Registered Post) Home Address Address: Postal Address (if applicable, write same as home ) Address: Suburb: Suburb: State: Postcode: State: Postcode: Country: Country: Part B: Declaration Declaration: The information that I have given in, or in connection with, this form is true and correct. Printed Name: Signed: v4.1 www.msic.net.au Veritas
Application Identification Number Replacement MSIC: Lost, Damaged, Stolen or Change of Type Form (Issuing Body Use Only) Part C: Lost, Damaged, Stolen or Change of Type Please provide answers to the following questions: a) Have you lost your MSIC? If you ticked to (a) above, you will need to: provide a statutory declaration setting out the circumstances of the loss or destruction of the MSIC; and o with this declaration, a provide statement that since your background check was completed, whether or not you have been convicted of an maritime-security relevant offence b) Has your MSIC been damaged, defaced, or altered? If you ticked to (b) above, you will need to: provide a statutory declaration setting out the circumstances of the loss or destruction of the MSIC; and o with this declaration, a provide statement that since your background check was completed, whether or not you have been convicted of an maritime-security relevant offence c) Has your MSIC been stolen? If you ticked to (c) above, you will need to: provide a copy of a police report or other information issued by the police regarding the theft provide a statutory declaration stating that since your background check was completed, whether or not you have been convicted of an maritime-security relevant offence Have you attached a copy of the police report? d) Do you need to change your type of MSIC (e.g. get a replacement blue MSIC in substitution for a white MSIC, or vice versa)? If you ticked to (d) above, you will need to: provide a statutory declaration stating that since your background check was completed, whether or not you have been convicted of an maritime-security relevant offence Part D: Sponsoring Organisation TAX INVOICE Veritas Engineering Pty Ltd ABN 57 107 945 988 If your employer has established an account with Veritas Engineering and has agreed to pay for your replacement MSIC, please list that organisation here. Processing shall not commence until verified: Sponsoring Organisation: Business Unit (if applicable): Part E: Payment Details Total Amount Payable for Replacement MSIC: $121.00 (includes GST of $11.00) Submit this form and supporting documentation using one of the options listed below. If your employer requires you to make payment for your MSIC, payment options are also listed. The date signed by the interviewer on the reverse side of this form constitutes the date of form acceptance. Email completed application to: msic@veritasgroup.com.au OR Post to: PO BOX 7696, Cloisters Square WA 6850 For payment by credit card (VISA, MasterCard, AMEX*): Credit Card Number: - - - Expiry: / Amount: CVV^: ^ (3 digit for VISA/MC or 4 digit for AMEX) Name on card: Signature: * Credit Card Fees: Visa/MasterCard/AMEX 1.5% Part F: Card Issue (Issuing Body Use Only) Authorisation to issue (Issuing Body Rep.) Signed: Print: Collected by (Applicant) Signed: Print: v4.1 www.msic.net.au Veritas
Commonwealth of Australia STATUTORY DECLARATION Statutory Declarations Act 1959 1 Insert the name, address and occupation of person making the declaration 2 Set out matter declared to in numbered paragraphs I, 1 make the following declaration under the Statutory Declarations Act 1959: 2 Since my background check was completed, I have not been convicted of a maritime-security relevant offence. I understand that a person who intentionally makes a false statement in a statutory declaration is guilty of an offence under section 11 of the Statutory Declarations Act 1959, and I believe that the statements in this declaration are true in every particular. 3 Signature of person making the declaration 4 Place 5 Day 6 Month and year 7 Signature of person before whom the declaration is made (see over) 8 Full name, qualification and address of person before whom the declaration is made (in printed letters) 3 Declared at 4 on 5 of 6 Before me, 7 8 te 1 A person who intentionally makes a false statement in a statutory declaration is guilty of an offence, the punishment for which is imprisonment for a term of 4 years see section 11 of the Statutory Declarations Act 1959. te 2 Chapter 2 of the Criminal Code applies to all offences against the Statutory Declarations Act 1959 see section 5A of the Statutory Declarations Act 1959.
A statutory declaration under the Statutory Declarations Act 1959 may be made before (1) a person who is currently licensed or registered under a law to practise in one of the following occupations: Chiropractor Dentist Legal practitioner Medical practitioner Nurse Optometrist Patent attorney Pharmacist Physiotherapist Psychologist Trade marks attorney Veterinary surgeon (2) a person who is enrolled on the roll of the Supreme Court of a State or Territory, or the High Court of Australia, as a legal practitioner (however described); or (3) a person who is in the following list: Agent of the Australian Postal Corporation who is in charge of an office supplying postal services to the public Australian Consular Officer or Australian Diplomatic Officer (within the meaning of the Consular Fees Act 1955) Bailiff Bank officer with 5 or more continuous years of service Building society officer with 5 or more years of continuous service Chief executive officer of a Commonwealth court Clerk of a court Commissioner for Affidavits Commissioner for Declarations Credit union officer with 5 or more years of continuous service Employee of the Australian Trade Commission who is: (b) authorised under paragraph 3 (d) of the Consular Fees Act 1955; and Employee of the Commonwealth who is: (b) authorised under paragraph 3 (c) of the Consular Fees Act 1955; and Fellow of the National Tax Accountants Association Finance company officer with 5 or more years of continuous service Holder of a statutory office not specified in another item in this list Judge of a court Justice of the Peace Magistrate Marriage celebrant registered under Subdivision C of Division 1 of Part IV of the Marriage Act 1961 Master of a court Member of Chartered Secretaries Australia Member of Engineers Australia, other than at the grade of student Member of the Association of Taxation and Management Accountants Member of the Australasian Institute of Mining and Metallurgy Member of the Australian Defence Force who is: (a) an officer; or (b) a non-commissioned officer within the meaning of the Defence Force Discipline Act 1982 with 5 or more years of continuous service; or (c) a warrant officer within the meaning of that Act Member of the Institute of Chartered Accountants in Australia, the Australian Society of Certified Practising Accountants or the National Institute of Accountants Member of: (a) the Parliament of the Commonwealth; or (b) the Parliament of a State; or (c) a Territory legislature; or (d) a local government authority of a State or Territory Minister of religion registered under Subdivision A of Division 1 of Part IV of the Marriage Act 1961 tary public Permanent employee of the Australian Postal Corporation with 5 or more years of continuous service who is employed in an office supplying postal services to the public Permanent employee of: (b) a State or Territory or a State or Territory authority; or (c) a local government authority; with 5 or more years of continuous service who is not specified in another item in this list Person before whom a statutory declaration may be made under the law of the State or Territory in which the declaration is made Police officer Registrar, or Deputy Registrar, of a court Senior Executive Service employee of: (b) a State or Territory or a State or Territory authority Sheriff Sheriff s officer Teacher employed on a full-time basis at a school or tertiary education institution
A statutory declaration under the Statutory Declarations Act 1959 may be made before (1) a person who is currently licensed or registered under a law to practise in one of the following occupations: Chiropractor Dentist Legal practitioner Medical practitioner Nurse Optometrist Patent attorney Pharmacist Physiotherapist Psychologist Trade marks attorney Veterinary surgeon (2) a person who is enrolled on the roll of the Supreme Court of a State or Territory, or the High Court of Australia, as a legal practitioner (however described); or (3) a person who is in the following list: Agent of the Australian Postal Corporation who is in charge of an office supplying postal services to the public Australian Consular Officer or Australian Diplomatic Officer (within the meaning of the Consular Fees Act 1955) Bailiff Bank officer with 5 or more continuous years of service Building society officer with 5 or more years of continuous service Chief executive officer of a Commonwealth court Clerk of a court Commissioner for Affidavits Commissioner for Declarations Credit union officer with 5 or more years of continuous service Employee of the Australian Trade Commission who is: (b) authorised under paragraph 3 (d) of the Consular Fees Act 1955; and Employee of the Commonwealth who is: (b) authorised under paragraph 3 (c) of the Consular Fees Act 1955; and Fellow of the National Tax Accountants Association Finance company officer with 5 or more years of continuous service Holder of a statutory office not specified in another item in this list Judge of a court Justice of the Peace Magistrate Marriage celebrant registered under Subdivision C of Division 1 of Part IV of the Marriage Act 1961 Master of a court Member of Chartered Secretaries Australia Member of Engineers Australia, other than at the grade of student Member of the Association of Taxation and Management Accountants Member of the Australasian Institute of Mining and Metallurgy Member of the Australian Defence Force who is: (a) an officer; or (b) a non-commissioned officer within the meaning of the Defence Force Discipline Act 1982 with 5 or more years of continuous service; or (c) a warrant officer within the meaning of that Act Member of the Institute of Chartered Accountants in Australia, the Australian Society of Certified Practising Accountants or the National Institute of Accountants Member of: (a) the Parliament of the Commonwealth; or (b) the Parliament of a State; or (c) a Territory legislature; or (d) a local government authority of a State or Territory Minister of religion registered under Subdivision A of Division 1 of Part IV of the Marriage Act 1961 tary public Permanent employee of the Australian Postal Corporation with 5 or more years of continuous service who is employed in an office supplying postal services to the public Permanent employee of: (b) a State or Territory or a State or Territory authority; or (c) a local government authority; with 5 or more years of continuous service who is not specified in another item in this list Person before whom a statutory declaration may be made under the law of the State or Territory in which the declaration is made Police officer Registrar, or Deputy Registrar, of a court Senior Executive Service employee of: (b) a State or Territory or a State or Territory authority Sheriff Sheriff s officer Teacher employed on a full-time basis at a school or tertiary education institution
Statement of Operational Need for a Maritime Security Identification Card (MSIC) Application Identification Number Please email your signed Statement of Operational Need letter to: msic@veritasgroup.com.au An MSIC will not be issued until a signed Statement of Operational Need is received for each applicant. Employers may complete this letter on behalf of their employees, contractors, or other authorised persons to serve as documentary evidence of the listed applicants' Operational Need to possess either a blue MSIC or white MSIC. I acknowledge that a person has an Operational Need to hold a blue MSIC if his or her occupation or business interests require, or will require, him or her to have unmonitored access to a maritime security zone at least once each year (in accordance with the Maritime Transport and Offshore Facilities Security Regulations 2003, Section 6.07F(1)). I acknowledge that a person has a has an operational need to hold a white MSIC if the person is required to be directly involved in the issue of MSICs for an issuing body (in accordance with the Maritime Transport and Offshore Facilities Security Regulations 2003, Section 6.07F(2), 6.07B(1)). I confirm that the following individual possesses an Operational Need for the type of MSIC selected: Full Name Why does the individual require an MSIC? Unmonitored Access Frequency MSIC Type Blue MSIC White MSIC The above named individual also understand that it is an offence to retain their MSIC if they no longer possess an Operational Need for it (i.e. MSIC must be returned to the Issuing Body within 30 days if their operational need no longer exists as per Section 6.08Q of the Regulations). Name: Sign: Organisation: Address: Contact Number: Position: ABN: Email: Payment Details Applicant to pay Company to pay. Business unit / project (if applicable) Purchase order number or cost code Select if MUST be: 2 years 4 years (not applicable for White MSICs) Applicant to select