Criminal record and insolvency declaration

Fundraising Act 1998

This form must be completed by:

 all individual applicants seeking registration as a fundraiser; and
 all persons nominated as an associate (an associate is any other person who has significant influence over
the management or operation of your fundraising activities); and
 all individuals nominated as appeal managers (an appeal manager is any person or organisation who has
managerial or financial responsibility for any fundraising activities); and
 all persons authorised by appeal manager organisations to complete the form on behalf of the organisation.
Provide a separate form for each person named on the application.

Eligibility
To be eligible for registration, a company or any person (appeal manager, associate or any other person) who has
managerial or financial responsibility for or significant influence over any fundraising funds cannot be:
 insolvent or under external administration; or
 a represented person under the Guardianship and Administration Act 1986 (where a guardian or
administrator has been appointed); or
 a person who has committed a disqualifying offence (an offence involving fraud, dishonesty, violence or
drug trafficking that is punishable by imprisonment for 3 months or more in the case of a natural person, or
by a fine of $10,000 or more in the case of a body corporate; or an offence under the Fundraising Act 1998).

Fundraiser name
Name of fundraiser or
proposed fundraiser

Name and details

Enter your name, or if you have been authorised to complete the form on behalf of an organisation, the name of the
organisation.

Full name

Date of birth
dd/mm/yyyy

Contact address
Include postcode
PO Boxes accepted

What will be your role in the fundraiser?

Mark with an ‘X’ all that apply.

Individual registrant
You are the person applying to be registered.

Appeal manager
You or the organisation which authorised you to complete this form, will have managerial or financial
responsibility for any fundraising activities.

Associate
You have significant influence over the management or operation of your fundraising activities.

consumer.vic.gov.au/fundraisers Page 2 of 2
 Declaration
I, the person whose signature is set out below:
 declare that the individual or organisation named above have not pleaded guilty to, been convicted of or had
a charge proven for a disqualifying offence capable of being punished by imprisonment for 3 months or
more (whether or not a penalty of imprisonment was imposed);
 declare that the individual or organisation named above have not been bankrupt within the last 10 years;
 declare that the individual or organisation named above have not been subject to any other forms of
insolvency administration within the last 10 years or been externally administered within the last 10 years;
and
 acknowledge that this declaration is true and correct; and
 acknowledge that it is an offence under section 62 of the Fundraising Act 1998 to make a false or
misleading statement in relation to an application for fundraiser registration.

Signature of declarer
Must be witnessed

This date
dd/mm/yyyy

Full name of witness

Signature of witness

Privacy
For privacy information, please refer to the Privacy statement page on the Consumer Affairs Victoria website
(consumer.vic.gov.au/privacy).

consumer.vic.gov.au/fundraisers Page 2 of 2