Version 3
Form 51
QUEENSLAND
Corrective Services Act 2006 (s. 190)
LEAVE TO APPEAR OR BE REPRESENTED BY AN AGENT
BEFORE A PAROLE BOARD
Prisoner:
[name of prisoner]
Date of Birth:
[insert DOB]
Location:
[insert facility that prisoner is currently accomodated in]
Identification Number: [insert ID number]
TO the Secretary of the Queensland Parole Board / [insert relevant] Regional
Board (the Board).
I, the above named prisoner, seek the leave of the Board to—
*appear before the [insert relevant Parole Board or
* be represented by an agent before the—
[insert relevant Parole Board].
in relation to my application for a parole order.
The name and address of my agent is:
Name: [insert name of agent]
Address: [insert agent' s address]
Telephone Number: [insert agent's telephone number]
Information in support of this application:
[insert relevant information]
I have attached the further supporting information in relation to my nominated
agent
Signature:____________________
Date: …./…./….
*Delete whichever is inapplicable
Form 51 – Corrective Services Act 2006
*Further Supporting Information for Application to Be Represented by
Agent (to be completed by the nominated agent)
If you have applied, or been nominated, to appear before the parole board in
support of a prisoner’s parole application you are requested to provide the
following information. The information you provide will be used by the parole
board to determine whether to grant leave for you to appear in support of the
prisoner’s parole application.
If you require more space to respond to the questions please attach a
separate document.
What is your relationship to the prisoner? (for example: family member, friend, or
a professional relationship such as counsellor and client)
Please provide details of your level of education, qualifications and
experience.
Are you a member of any professional bodies that require members to
comply with a code of conduct? (A code of conduct refers to expected standards of
behaviour of members of a professional body. A code of conduct would usually include a
requirement to act honestly, with integrity and in accordance with accepted professional
standards)
Do you have any convictions recorded against you for an indictable
offence or an offence of dishonesty? If yes, please provide details.
(A conviction is a finding of guilt, or the acceptance of a plea of guilty, by a court. An
indictable offence is an offence that is tried before a court other than a court exercising
summary jurisdiction- an indictable offence is usually tried in the District or Supreme Court.
An offence of dishonesty means an offence involving fraud, deception, misappropriation,
assuming a false identity or the making of false statements)
Are you currently subject to disciplinary or criminal proceedings? If
yes, please provide details.
What fees do your propose to charge the prisoner for representing
them?
Signature:
____________________
Name of agent:
____________________
Name of prisoner: ____________________
Date: …./…./….
Form 51 – Corrective Services Act 2006
Form 51 Information Privacy Notice
Sections 190 and 341 of the Corrective Service Act 2006
The Department of Community Safety is collecting the information on this form
for the following purposes:


to consider and determine the applicant’s request for representation
by an agent; and
for the Department to discharge its legislative, accountability,
administrative, reporting, management, personnel and financial
functions.
Collection of this information is authorised/required by the Corrective Service
Act 2006.
The Department of Community Safety may give some or all of this information
to the other State, Territory, or Commonwealth parole authorities.
In addition to the above uses and disclosures, your personal information may
also be used and disclosed as per the Queensland Corrective Services
Offender Privacy Statement. The statement has been provided to all offenders
and is also available in accommodation units, offender libraries and
movement control stations where applicable.