| A.
Training |
| Have
you completed
the Chubb
online training
: |
|
| B.
Personal
Details |
| Given
Name(s): |
|
| Surname: |
|
| Other
Name(s): |
|
| Residential
Address: |
|
| Suburb: |
|
| State & Postcode: |
|
| Postal
Address: |
|
| (If
same as residential,
please type "As
Above") |
| Home
Phone Number: |
|
| Work
Phone Number: |
|
| Mobile
Phone Number: |
|
| Email
Address: |
|
| Name
of Employer: |
|
| Date
of Birth: |
|
| Select
type of MSIC
required: |
Standard
MSIC (Over
18) |
|
| Provisional
MSIC (Under
18) |
|
| Renewal
of Standard
MSIC (Replacement
card) |
|
MSIC
based on
ASIC
|
|
If
you selected
MSIC based
on ASIC,
please supply
your ASIC
number
and
ASIC Expiry Date:
|
| C.
Documentation
Required |
You
will need
to produce
documents
at your
interview
that:
• Confirm
your identity;
• Confirm
your right
to work in
Australia;
• Confirm
your operational need.
Please mark the box next to the document you will provide.
In general, you should produce original documents. Legally certified copies of
documents
are acceptable in some circumstances, please contact Chubb for assistance.
Identification
Documents
• One (1) primary document and one (1) secondary document or
• One (1) primary document and two (2) tertiary documents.
|
| Primary
Documentation |
Full
Birth Certificate,
Australian
or foreign |
|
| Australian
Citizenship
/ naturalization
papers |
|
| A
legally issued
foreign document
evidencing
citizenship
of that country. |
|
Passport,
Australian
or foreign,
valid for
travel
within
the last
2 years.
|
|
| Secondary
Documentation
(One Required.
Must have
your signature
or recent
photo) |
Australian
Commonwealth,
State or
Territory
license
(i.e. Driver's
or shooters
license)
|
|
Australian
Commonwealth,
State or
Territory
Government
employee
ID
|
|
Australian
tertiary
student
ID
|
|
Verifiable
reference
(Contact
Chubb for
assistance)
|
|
| Tertiary
Documentation:
(Two required.
Must have
your name
and address) |
Employee
statement
or reference
signed
by employer
|
|
| Australian
Lands Titles
Office Record |
|
| Australian
Council rates
notice or
record of
ownership
or residence |
|
| Australian
Electoral
roll extract |
|
Another
Australian
legal record
(e.g. tax
file number
advice,
jury duty
notice,
speeding
ticket)
|
|
Translations - are any
of your documents
in a foreign
language?
If 'yes', full translations will be required. Contact Chubb for advice on
translation requirements. |
|
Change
of Name -
Are all your
documents
in the name
you currently
use?
If 'no',
you will
need to provide
evidence
of change
of name such
as a marriage
certificate
or other
legal documents.
Contact Chubb
for advice
if required, |
|
Right
to Work - Are you
an Australian
Citizen?
If 'yes',
you will
need to provide
one of the
following:
• Australian
citizenship
/ naturalization
papers.
• Australian passport issued after the 22 November 1984.
• Australian birth certificate issued before 20 August 1986.
•
Australian
birth certificate
issued
after
20 August 1986 and evidence that you spent your first ten years in Australia,
or
that one of your parents was Australian citizen or permanent resident when you
were born. Contact Chubb for advice if required.
•
Extract from the register of Australian Citizenship by descent.
|
|
Australian
Resident
- are
you an
Australian
permanent
resident?
If 'yes',
you will
need to
confirm
this by
producing
a passport
with a
visa confirming
this, or
a certificate
of evidence
of resident
status.
Contact
Chubb for
advice
if required.
Chubb may
need to
confirm
your right
to work
with DIMA. |
|
Temporary
Resident
- are
you a temporary
resident?
If 'yes', you will need to show a valid passport with current visa giving
you permission to work. Your right to work will be confirmed with The Department
of Immigration and Multicultural and Indigenous Affairs(DIMA). |
|
| Type
of Operational
Need |
| Please
select the
operational
need that
best suits: |
I
am:
|
Person
who works
for the
maritime
industry
|
|
Person
who has
a business
connection
with the
maritime
industry
|
|
Representative
of an employee
association
whose members
access
a maritime
security
zone
|
|
Representative
of a maritime
or offshore
industry
association
|
|
At
the application
interview
please
present
proof of
operational
need such
as a letter
from your
employer,
the company
they are
contracted
to, or
a Port
Authority.
The letter
must be
an original
and on
company
letterhead.
|
| Payment
Options |
| Please
select below
the method
of payment
for your
MSIC card: |
| Cheque
(must be
presented
at time of
application) |
|
| Cash
(must be
presented
at time of
application) |
|
Credit
Card (will
be debited
upon submission
of application)
|
|
If
you selected
Credit
Card, please
indicate
Credit
Card type.
|
|
| Photo |
Please
indicate
if you
will be
providing
a photograph
or require
Chubb to
take a
photo at
time of
application,
free of
charge.
|
| Own
photograph. |
|
| Chubb to
take photograph. |
|
SUBMIT |
|
|
