FORM A
COMMONWEALTH OF AUSTRALIA
STATUTORY DECLARATION	
	I,   		
	of   		
 	
	Being the applicant for the issue of a liquor licence/appointment as nominee as provided by the Airports (Control of On-Airport) Activities Regulations 1997 (as amended), do solemnly and sincerely declare that:
1.	I was born on      in the town/city of   

in the State / Country of   
2.	I am a Citizen/Permanent Resident of  
3.	I have/have never been the subject of a conviction, finding of guilt or pecuniary penalty before a Court.
Please attach your probity report obtained from the Federal Police
4.	I am not, nor have I ever been a director or secretary of a company that has been the subject of a conviction finding of guilt or pecuniary penalty before a Court, Tribunal or a Liquor Licensing Board of any State or Territory.
5.	I am not an undischarged bankrupt.
Please attach your credit history obtained from Credit Australia Limited
6.	No company of which I have been a director or secretary been declared bankrupt or placed in liquidation. 
PERMANENT RESIDENTIAL ADDRESSES OVER LAST FIVE YEARS
 
Period of Residence

TO

TO

TO

 	
	
Form A - Statutory Declaration - Page 2	
	PREVIOUS LIQUOR LICENCES HELD

OTHER RELEVANT WORKING EXPERIENCES ON LICENSED PREMISES

I make this solemn declaration by virtue of the Statutory Declarations Act 1959 (as amended) and subject to the penalties provided by the Act for the making of false statements in statutory declarations, conscientiously believing the statements contained in this declaration to be true in every particular.

Declared at      on    
Before me, 

Signature and title of person before whom the declaration is made.
(Commissioner for Declarations Justice of the Peace or a Public Servant of 5 years standing)

Note: A person who wilfully makes a false statement in a statutory declaration under the Statutory Declarations Act 1959 (as amended) is guilty of an offence against that Act, the punishment of which is a fine not exceeding $200 or imprisonment for a term not exceeding 6 months or both if the offence is prosecuted summarily, or imprisonment for a term not exceeding four years if the offence is prosecuted upon indictment