Confidential Application Form: Corrective Services & Civilian Watchhouse Officers

First name

Middle name

Last name

Title

Mr

Mrs

Miss

Ms

Other

Date of birth

Residential address

Postal address

Contact number

Email address

Work email address

Emergency contact (optional)

Emergency contact relationship

Emergency contact address

Emergency contact phone number

Employer (Agency/Service)

Rank and position

Registered Number/Employee Number

Current employment location (town/city)

Any other current ongoing employment

Date of joining current Agency

Details of previous service (Defence/Law Enforcement/Ambulance Service - of another State Country) including dates and reasons for termination/retirement

I heard about Sibley Lawyers via;

Internet Search

From a friend, relative or colleague

Other

If you heard about Sibley Lawyers from a friend, relative or colleague, please state their name

My preferred method of contact is:

Text

Email

Phone

I am the subject of any of the following outstanding matters;

A criminal charge

A disciplinary proceeding

An investigation/request for information from a discipline/compliance or investigative group

I am aware of circumstances that could result in a criminal or disciplinary matter being initiated against me in the next 24 months

Yes

No

During the past 5 years I have been the subject of a criminal charge, disciplinary investigation or hearing

Yes

No

During the past 3 years I have had a complaint made against me by a member of the public, or been questioned in relation to my professional conduct

Yes

No

Have you suffered a work place injury or developed any symptoms within the last 3 years

Physical

Psychological

Both physical and psychological

No injury

Sibley Lawyers are not Personal Injury specialists. We cannot provide you with any advice regarding inury matters. There are strict time frames that apply to injury claims, and you should engage with our trusted partner Rogalski Lawyers to safeguard your claims. We are not responsible for reminding you of due dates, or providing you advice regarding time limits. We will not be taking any steps to protect your claim or any potential time limits.

Do you consent to us referring you to our trusted partners injury specialists Rogalski Lawyers for a free consultation?

Yes

No

If yes: do you consent to Rogalski Lawyers and Sibley Lawyers sharing relevant information about you between each other to assist both firms to represent you?

Yes

No

During the last 12 months I have been issued a show cause letter, or any other form of management letter in relation to my work performance

Yes

No

If yes to any of the above, please use the following free field to provide as much detail as you can about the matter you have identified

I am interested in;

Top level protection at $990 per annum including GST (paid fortnightly/monthly or annually);

1. Criminal defence commencing from incident or disciplinary investigation;
2. 24/7 legal advice in the event of a critical incident;
3. General Employment Law advice;
4. Workers' compensation claims, reviews, and appeals;
5. Disciplinary investigation support and legal representation;
6. Advice and support regarding general workplace matters.

I am a member of a union and/or association

Yes

No I’m not a member of a union or association

I am interested in paying my annual retainer and premium

Up front

Fortnightly

Monthly

Submit

Note: Your completed application form will be relied upon as a basis to consider entering into a client service agreement with you. If formalised, only the client is authorised to access the services covered by the retainer with Sibley Lawyers, and benefit from the retainer. All correspondence will be directed to the retained client unless indicated otherwise. You have an ongoing obligation to disclose all and any matters you know, or that a reasonable person could be expected to know, would be relevant to our decision to enter into a client agreement with you. The firm reserves the right not to offer you an agreement to enter into a client retainer with you for any reason, or to amend the agreement if circumstances become known that would have affected our decision to enter into an agreement with you.

*** Any information provided in answer to this or any future questionnaires/conferences will be treated as confidential client/lawyer privilege.