Department of Communities,
Child Safety and Disability Services
Application for replacement of lost or stolen
positive notice and card or positive
exemption notice and card
Form 10-3
For use by a disability services positive notice or positive exemption notice holder whose
positive notice/card has been lost or stolen.
Disability Services Act 2006 Section 92.
Under the Disability Services Act 2006, a person
is required to provide written notice of the loss
or theft of a positive notice and card or positive
exemption notice within 14 days. It is an offence
not to provide this notice within 14 days.
How to complete this form
If your lost or stolen positive notice and card or
positive exemption notice is recovered or returned
to you, you must give the recovered or returned
notice or card to the department within 14 days.
It is an offence not to give your recovered or
returned positive notice and card or positive
exemption notice to the department within 14 days.
• Please print clearly, use BLOCK letters and
indicate with a tick where required.
The department is required by law to report the
loss or theft of positive notices and cards or
positive exemption notices to the Queensland
Police Service.
Form 10-3
Version 9 June 2016
Page 1 of 5
0246 JUNE 2016
• All parts must be completed by the person
who has been issued with a positive notice
and positive notice card.
PRIVACY NOTICE
The department is collecting your personal
information on this form in order to provide you
with a replacement positive notice or positive
exemption notice as authorised under the Disability
Services Act 2006. Your personal information may
be provided to the Queensland Police Service
in order to notify them of the loss or theft. Your
personal information will be managed in accordance
with the Information Privacy Act 2009.
PART A – Personal details
Title:
Mr
Mrs
Ms
Mailing address: (if different from home address)
Gender:
Family name:
Contact number:
Given name:
Middle name:
Date of birth:
Home address:
Mobile:
Work:
Home
Contact email:
Personal:
Work:
PART B – Positive notice/exemption notice details
Positive notice or positive exemption notice
number (if known):
Indicate by ticking the appropriate box/boxes
whether it is your positive notice or positive
notice card or both which has/have been lost
or stolen:
Positive notice
Positive notice card
Positive exemption notice
Positive exemption notice card
Indicate by ticking the appropriate box whether
your positive notice/positive notice card was
lost or stolen:
Lost
Stolen
Form 10-3
Version 9 June 2016
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Date of loss or theft (write unknown if date unknown):
Have you reported the loss or theft to the
police (tick one)?
Yes
No
If you did report the loss or theft to the police,
what date did you report it and to what police
station did you report it?
Date:
Police station:
PART C – Return of document/card
A positive notice or exemption notice is issued
with a positive notice card or exemption notice
card. If one of these is lost or stolen, you must
return the other document.
Tick one of the following to indicate the document
or card you are returning:
Please find enclosed:
Positive notice
For example, if your positive notice card is lost but
you still have your positive notice, you must return
your positive notice.
Positive notice card
Positive exemption notice
Positive exemption notice card
None of the above – both my positive notice/
exemption notice and my positive notice card/
exemption notice card have been lost or
stolen
PART D – Declaration
• I declare that the information that I have
provided in this form is true and correct.
Signature:
Date:
• I understand that it can be an offence under
the Disability Services Act 2006 to state anything
in this form that is false or misleading.
• I understand the privacy notice in this form and I
consent to the collection, use and disclosure of
my personal information in the manner described
in that notice.
Return to:
Department of Communities, Child Safety and Disability Services
PO Box 10179, BRISBANE ADELAIDE STREET QLD 4001
OR
criminalhistoryscreening@disability.qld.gov.au
Phone: 1800 183 690 / Fax: 07 3405 6422
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Version 9 June 2016
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Form 10-3
Version 9 June 2016
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PART E – Payment details
This application is not considered lodged unless it is accompanied by the prescribed fee. This section must
be completed. Please note that the application fee is non-refundable and subject to change.
Please select one of the following payment methods:
Credit card (complete details below)
Cheque
Money Order
Cheque/Money Order payable to:
Department of Communities, Child Safety and Disability Services
ABN 25 791 185 155
Please charge $13.05 to: Mastercard
Visa
Name of credit card holder
Number:
Cardholder’s Signature
Expiry Date
Who is the payment receipt to be made out to?
/
Where is the receipt to be sent (email/post)?
Form 10-3
Version 9 June 2016
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