<p> 0905 Criminal record and personal insolvency declaration</p><p>Fundraising Act 1998 This form must be completed by:</p><p> all individual applicants or all directors of a company applicant, and key committee members of incorporated associations; and  all persons nominated as appeal managers (an appeal manager is any person who has managerial or financial responsibility for any fundraising activities); and  all persons nominated as an associate (an associate is any other person who has significant influence over the management or operation of your fundraising activities).</p><p>Provide a separate form for each person named on the application. Ineligibility</p><p>Under section 19A(1(a) and (b)) of the Fundraising Act 1998 the Director (of Consumer Affairs Victoria) must not register a person as a fundraiser if the person, or any person named in the application as an appeal manager is an insolvent under administration or is an externally-administered body corporate; or has been found guilty of a disqualifying offence. A disqualifying offence is defined as an offence involving:</p><p> fraud, dishonesty, violence or drug trafficking  punishable by imprisonment for three months or more in the case of a natural person, or by a fine of $10,000 or more in the case of a body corporate; or  an offence under the Fundraising Act 1998. Privacy</p><p>For privacy information, please refer to the Privacy statement page on the Consumer Affairs Victoria website (consumer.vic.gov.au/privacy).</p><p>Fundraiser name</p><p>Name of fundraiser/proposed fundraiser</p><p>Declaration</p><p>I, the person whose signature is set out below declare that I have not pleaded guilty to, been convicted of or had a charge proven for an offence capable of being punished by imprisonment for 3 months or more (whether or not a penalty of imprisonment was imposed), or have been bankrupt within the last 10 years; been subject to any other forms of insolvency administration within the last 10 years, or been externally administered within the last 10 years.</p><p>Full name</p><p>Date of birth dd/mm/yyyy</p><p>(08/2016)</p><p> consumer.vic.gov.au/fundraisers Page 1 of 2 Residential address Including postcode.</p><p>Fundraising capacity Refer to definitions given above and mark with an ‘X’ all that apply.</p><p>Person applying for registration</p><p>Appeal manager</p><p>Associate who has significant influence</p><p>I acknowledge that this declaration is true and correct. I acknowledge that it is an offence under section 62 of the Fundraising Act 1998 to make a false or misleading statement in relation to an application for fundraiser registration.</p><p>Declared at Address.</p><p>This date dd/mm/yyyy</p><p>Signature of person making this declaration Must be signed in front of the witness.</p><p>Signature of witness</p><p>How to lodge</p><p>Post: Assistance:</p><p>Consumer Affairs Victoria Telephone: 1300 13 54 52 GPO Box 4567 NRS: 133 677 Melbourne VIC 3001 ABN: 32 790 228 959 Email: [email protected] Web: consumer.vic.gov.au/fundraiser</p><p>(08/2016)</p><p> consumer.vic.gov.au/fundraisers Page 2 of 2</p>