Confidential Application Form: Crowd Controller

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

Current employment location (town/city):

Details of previous employment for the last five years 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 10 years I have been the subject of a criminal charge, disciplinary investigation or hearing

Yes

No

During the past 5 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

During the last 5 years 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 possible:

I am interested in;

Basic level protection at $550 per annum including GST;

1. Criminal defence and associated discipline 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

How many hours do you estimate you work on average?

Do you have any other employment outside of your role as a crowd controller/security guard?

Yes

No

If yes, are you interested in seeking employment related cover for your other employment as well?

Yes

No

Details of other employment (if applicable)?

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.