Commonwealth of Australia 92, 015 (03/2014)
STATUTORY DECLARATION
Statutory Declarations ACT 1959
1 Insert the name, name
address and I, 1
occupation of
person making address
the declaration
occupation
make the following declaration to the Australian Medical Council under the Statutory
Declarations Act 1959:
2 Set out matter 2
declared to in
numbered
paragraphs
STOP you must print this statutory declaration and sign it in front of an eligible witness.
Refer to pages 2 and 3 of this form for eligible witnesses IN Australia - ONLY.
PRINT
Refer to the AMC Candidate Account Guide for the Identity - Statutory Declaration section
for eligible witnesses in countries OTHER than Australia - ONLY.
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
3 Signature of
person making
the declaration
4 Place 5 6
5 Day Declared at 4
place day month, year
6 Month and year on of
7 Signature of
7
person before
whom the Before me
declaration is made
8 Full name, 8 full name
qualification
and address of
person before
qualification
whom the
declaration is
made (in printed
letters) address
Note 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.
Note 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:
Architect Chiropractor Dentist
Financial adviser Financial Planner Legal practitioner
Medical practitioner Midwife Migration agent registered under
Division 3 of Part 3 of the Migration
Act 1958
Nurse Occupational therapist 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:
Accountant who is:
a) a fellow of the National Tax Accountants’ Association; or
b) a member of any of the following:
i. Chartered Accountants Australia and New Zealand;
ii. the Association of Taxation and Management Accountants;
iii. CPA Australia;
iv. the Institute of Public Accountants
Agent of the Australian Postal Corporation who is in charge of an office supplying postal services to the public
APS employee engaged on an ongoing basis with 5 or more years of continuous service who is not specified in
another item in this list
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 a Commonwealth authority engaged on a permanent basis with 5 or more years of continuous service
who is not specified in another item in this list
Employee of the Australian Trade and Investment Commission who is:
a) in a country or place outside Australia; and
b) authorised under paragraph 3 (d) of the Consular Fees Act 1955; and
c) exercising the employee’s function at that place
Employee of the Commonwealth who is:
a) at a place outside Australia; and
b) authorised under paragraph 3 (c) of the Consular Fees Act 1955; and
c) exercising the employee’s function at that place
Engineer who is:
a) a member of Engineers Australia, other than at the grade of student; or
b) a Registered Professional Engineer of Professionals Australia; or
c) registered as an engineer under a law of the Commonwealth, a State or Territory; or
d) registered on the National Engineering Register by Engineers Australia
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
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 the Australian Defence Force who is:
a) an officer
b) a non-commissioned officer within the meaning of the Defence Force Discipline Act 1982 with 5 or more years
of continuous service
c) a warrant officer within the meaning of that Act
Member of the Australasian Institute of Mining and Metallurgy
Member of the Governance Institute of Australia Ltd
Member of:
a) the Parliament of the Commonwealth
b) the Parliament of a State
c) a Territory legislature
d) a local government authority
Minister of religion registered under Subdivision A of Division 1 of Part IV of the Marriage Act 1961
Notary public, including a notary public (however described) exercising functions at a place outside
a) the Commonwealth
b) the external Territories of the Commonwealth
Permanent employee of the Australian Postal Corporation with 5 or more years of continuous service who is
employed in an office providing postal services to the public
Permanent employee of
a) a State or Territory or a State or Territory authority
b) a local government authority with 5 or more years of continuous service, other than such an employee who is
specified in another item of 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 employee of a Commonwealth authority
Senior executive employee of a State or Territory
SES employee of the Commonwealth
Sheriff
Sheriff’s officer
Teacher employed on a permanent full-time or part-time basis at a school or tertiary education institution