Northern Territory of Australia
Prostitution Regulation Act
Section 9(2)
Statutory Declaration by a Prostitute
(1)Insert full name
(2)
Residential address
(3)
If you do not have one of these types of name (e.g. you are not married) please write “not applicable” in the appropriate blank space
(4)
Write down the town, the State or Territory and the country in which you were born
(5)
E.g. black, fair, olive
(6)
E.g. any tattoos or scars you may have and where they are on your body
(7)
Delete as applicable
I, (1)
of (2)
previously resident at
do solemnly and sincere declare as follows:
a) My maiden name is (3)
My married name is (3)
My working name is (3)
My alias or work name is (3)
b) My date of birth is
c) I was born in (4)
d) Physical description:
i. I am / cm tall
ii. I weigh / Kg
iii. My complexion is (5)
iv. The colour of my eyes are
v. My natural hair colour is
My present hair colour is
vi. I have the following distinguishing features (6)
e) I (7) have / have not been convicted in the last 10 years of committing a serious drug offence or a violent offence, as those offences are defined in section 9(11) of the Prostitution Regulation Act, or of attempting to commit such an offence.
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(8a)Describe the offence. Use any documents you have from the Court, or, if you do not have any documents, briefly describe the incident, e.g. I hit someone
(8b)
Write the name of the Court e.g. Local Court, Magistrates Court, Supreme Court and the town or city that court was in e.g. Darwin, Sydney
(8c)
Write down the town or city and the State or Territory where the offence took place (e.g. Tennant Creek)
(9)
Write down the name and address of any escort agencies you have worked for, whether in the NT or elsewhere
(10)
Write down the name, address, and telephone number of the escort agency or agencies you intend to work for in the NT
(11)
Town or city you have signed this form e.g. Alice Springs
(12)
Witness’ full name, address and telephone number
f) If you have been convicted of an offence referred to it item (e), complete the following (8):
i. Date of conviction
Offence (8a)
Court (8b,c)
ii. Date of conviction
Offence (8a)
Court (8b,c)
g) I have provided prostitution services on behalf of the following agencies (9)
h) I intend to work as a prostitute for the following agencies (10)
and I make this solemn declaration by virtue of the provisions of the Oaths, Affidavits and Declarations Act and solemnly and sincerely declare that all statements and information contained in this declaration are true and correct to the best of my knowledge.
Signature
Declared at
(11)
on the / day of / 20
before me
(12)
Signature of Witness
Note:
(1) Witness must be someone who is over 18 years of age.
(2) A person wilfully making a false statement in a statutory declaration is liable to a fine or imprisonment.
(3) The applicant is required to attend and present this application to the front counter of a local Police Station along with the Application for Certificate that Prostitute is Free of a Finding of Guilt for Certain Offences form and an Authority to Release Criminal History form.
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Notice In Accordance with the Information Act (Information Privacy Principle 1)
Licensing NT (a division of NT Department of Business) is seeking information from you for the purposes of your application.
Information Privacy Principle 1 (IPP 1) requires that a public sector organisation must not collect personal information unless the information is necessary for one or more of its functions or activities. If personal information about an individual is collected from the individual, the organisation must take reasonable steps to ensure that the individual is aware of certain matters. For the purposes of IPP 1, the following advice is provided.
a) You are able to access your personal information that you have provided by making a written request to the Director-General of Licensing.
b) The information is required pursuant to the Prostitution Regulation Act. The Act requires that certain matters must be considered when deciding whether or not to approve an application.
c) The information will be kept confidential except as follows:
i) Information may be sought from Police, government agencies, interstate licensing authorities, or referees or other persons nominated by you. Information may be released to those sources to the extent necessary to verify information about you and your application.
ii) Registers of licences and permits will be maintained and may be made available to the public on request.
d) You do not have to provide information if you do not wish to do so. However, an application may not be approved if there is insufficient information to properly determine the matter in accordance with the Act.
Territory Business Centres - Toll free: 1800 193 111, e: /Darwin
Ground Floor, Development House
76 The Esplanade
Darwin
GPO Box 9800
Darwin NT 0801
t: (08) 8982 1700
f: (08) 8982 1725 / Katherine
Shop 1, Randazzo Building
18 Katherine Terrace
Katherine
PO Box 9800
Katherine NT 0851
t: (08) 8973 8180
f: (08) 8973 8188 / Tennant Creek
Shop 2, Barkley House
Cnr Davidson and Paterson Street
Tennant Creek
PO Box 9800
Tennant Creek NT 0861
t: (08) 8962 4411
f: (08) 8982 1725 / Alice Springs
Ground Floor, The Green Well Building
50 Bath Street
Alice Springs
PO Box 9800
Alice Springs NT 0871
t: (08) 8951 8524
f: (08) 8951 8533
Department of Business
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