The Brisbane Synagogue: Security Clearance Form

Surname *Please enter your surname

Given Name/s *Please enter your given name/s

Are you known or have you been known by any other name or spelling? *

If ‘Yes’, provide details:YesNo

Other name or spelling details. *

If you have checked "Yes" above, please enter the details here.

Date of Birth *

Country of Birth *

Citizenship (If multiple, list and date obtained) *

Mobile Number

Other Contact Number

Residential Address (currently residing) *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Other Addresses (last 5 years)

Email Address *

Occupation *

Place of Work/Study *

Relationship Status *

Name of Partner *

Maiden Name of Partner *

Partner Mobile Number

If Divorced/Separated, Name of Former Partner

Name of Children (include age) 1

Name of Children (include age) 2

Name of Children (include age) 3

What is your current Religion *

What Religion do your parents practice and where do they practice their religion *

Why are you interested in converting to Judaism / attending a service / joining this institution? *

Have you contacted any other Jewish community organisations? *

If ‘Yes’, provide detailsYesNo

Details of Jewish community organisations contacted *

Do you have any association with other Jewish community organisations? *

If ‘Yes’, provide detailsYesNo

Details of Jewish community organisations you have been associated with *

How did you find out about this organisation / institution? *

Are you currently, or have you ever been subject to a Good Behaviour Bond, an Interim Apprehended Violence Order or Interim Intervention Order? *

YesNo

If ‘Yes’, provide details *

Have you ever been investigated, charged or convicted of an offence involving firearms or weapons; terrorism; violence; organised crime; or an offence of a sexual nature? *

YesNo

If ‘Yes’, provide details *

In order for your application to be processed, please also provide: 1. A copy of your passport and driver’s license; and 2. Two written and signed personal character references (either current members of Jewish Community or previous employers), including

If online, please upload documents here

DECLARATION I declare that the information provided in this document is true and correct at the time of writing. I understand that any incorrect or withholding of information or documentation may result in my application for further information being denied. Furthermore, I authorise the Jewish Community (or representatives of it) to conduct a background check on myself if required and pass this application to Australian State and/or Federal Law Enforcement Agencies.

Full Name *

Date *

Signature

The Brisbane Synagogue

Security Clearance Form

(New visitors please complete)

Australian Jewish Community - SECURITY CLEARANCE FORM

Verification