Confirmation of Aboriginality or Torres Strait Islander Descent

Applicant Declaration

Date of Application:______

Applicant Name: ______

Applicant Signature:______

Signature of Parent/Guardian

(if applicant is under 15 years of age)

1. Have you ever received Confirmation of Aboriginality (COA) elsewhere? Please circle / YES/NO
1a. If yes, please provide a copy of COA or contact details of the service that provided the COA
2. Have you ever used the services of an Aboriginal organisation before? Please circle / YES/NO
2a If yes, please provide contact details of the Aboriginal organisation used previously

Please note: Confirming your Aboriginality requires proof of your heritage. Not all people will have this information at hand but it is important that you provide as much information as possible to ensure your application can be processed. Your application can only be submitted to the Goolum Goolum Aboriginal Co-operative Board for approval once all documentation has been provided. Please provide birth certificates where possible to indicate the linkages to your Aboriginal and/or Torres Strait Islander descent.

Applicant’s Details

Family Name:
Given Name:
Other Names : (e.g. Traditional, maiden, nicknames)
Tribe/Clan/Mob:
Current Residential Address:
Length of time at above address:
Date of Birth:
Place of Birth:
Daytime Phone No:
Father’s Family Name:
Father’s Given Names:
Mother’s Maiden Name:
Mother’s Given Names:

Please detail below or attach any additional information that can assist in your Confirmation of Aboriginality. For example family tree, photos, birth certificate, death certificate.

Please note: when the applicant is unknown to members of the Board or staff the following supporting evidence may be requested as an attachment:

  • Letter of Acknowledgment from a recognised and accepted member of the local Aboriginal community verifying to the best of their knowledge the Aboriginality of the Applicant;

Or

  • Letter of Acknowledgment from an Aboriginal organisation, community or recognised and accepted Aboriginal person from the applicant’s home community (interstate/intrastate) verifying to the best of their knowledge the Aboriginality of applicant.

Do you have any other relevant information which may support your application – e.g. photos, birth certificate or documentation? Please supply copies.

QFG-26 V3.0May2017

Hardcopies of this document are considered uncontrolled. Please refer to the Common Forms folder on the shared drive for the latest version.