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WESTERN AUSTRALIA POLICE FORCE ALCHOHOL AND DRUG COORDINATION UNIT LICENSING ENFORCEMENT DIVISION Application for Extension of 303 SEVENOAKS STREET CANNINGTON Time to Complete an Other WESTERN AUSTRALIA 6107 POST: LOCKED BAG 9 EAST PERTH WA 6892 Drug Intervention Session EMAIL: [email protected] TELEPHONE: (08) 9454 1454 The Other Drug Intervention Requirement notice you were given required you to book and attend three Other Drug Intervention Sessions (ODIS) within 42 days of it being given to you. Police chose to give you an opportunity to access intervention services and assistance instead of taking a criminal justice pathway for the prohibited drug-related offence(s) it is alleged you committed. If you consider there to be extenuating circumstances that have prevented you from complying with the intervention requirement by doing the three sessions in the 42 days allowed, you can use this form to fully explain the extenuating circumstances you consider excuse your non-completion of the requirement in the time allowed. Your application should include any references or documentation you have that can be used to verify your extenuating circumstances claim (eg. Medical Certificate, Hospital Admission records, Travel itinerary/ tickets, Work roster, etc.). Once your application has been considered you will be notified of the decision by phone or email. If your application is successful, you will be required to book and complete the required sessions by the extension date. Booking instructions and further assistance is available by contacting the WA Police Force Drug Diversion Coordinator on (08) 9454 1454. Applicant Details Family Name All Given Names Address Unit / Lot / Level Street Number Street Name Street Type Post Code State Suburb Home Phone Mobile Phone Email ODIR Details ODIR Number Date of Issue Application form continued over page. OFFICE USE ONLY Approved ( Y / N ) Applicant advised TAS Updated Booking Service Advised Other Drug Intervention Extension Version 1.0 30/08/2018 WESTERN AUSTRALIA POLICE FORCE ALCHOHOL AND DRUG COORDINATION UNIT LICENSING ENFORCEMENT DIVISION Application for Extension of 303 SEVENOAKS STREET CANNINGTON Time to Complete an Other WESTERN AUSTRALIA 6107 POST: LOCKED BAG 9 EAST PERTH WA 6892 Drug Intervention Session EMAIL: [email protected] TELEPHONE: (08) 9454 1454 Provide a valid reason for Extension EG: Medical Appointments, Work Commitments, ETC Request Extension date required Application made by Date Lodgement of Application Applications may be lodged by - Email [email protected] Fax (08) 9454 1535 Post Drug Diversion Coordinator Alchohol and Drug Coordination Unit Licensing Enforcement Division Locked Bag 9 EAST PERTH WA 6892 Assistance If you have any questions or require assistance with your application, you can contact the Drug Diversion Coordinator, Western Australia Police Force, on (08) 9454 1454 Other Drug Intervention Extension Version 1.0 30/08/2018.

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