Statutory Declaration, Witness Declaration and
Certified Copy of Proof of Identity
AVELING White Card Queensland
Instructions to Participant
So your qualification can be issued, please complete and return:
Part 1: Statutory Declaration. It must be signed by an Authorised Person, being either a: Justice of the Peace,
Commissioner for Declarations or Legal Practitioner**.
Part 2: Witness Declaration. A person must witness you doing the course and fill in Part 2. The witness must not
be related to you by blood or marriage.
Part 3: Participant Signature. This will be put onto the back of your White Card.
Part 4: Certified copy of a proof of identity. An Authorised Person must certify a copy of you proof of identity.
The completed Parts 1 to 4 and certified proof of identity must be forwarded to AVELING by either:
•
•
Email: [email protected]
Post:
AVELING Technical Support
184a Shepperton Road
East Victoria Park 6101
Western Australia
Important: This step is required by Queensland’s Department of Justice and Attorney General. AVELING cannot
process your qualification until done. Returning the relevant forms does not guarantee issuing of qualification (e.g.
where documents are incomplete or suspected to be untrue).
** Finding a Justice of the Peace, Commissioner for Declarations or Legal Practitioner
Part 1: Statutory Declaration and Part 4: Certified copy of a proof of identity must be certified by an Authorised
Person, being either a:
•
•
•
Justice of the Peace, or
Commissioner for Declarations, or
Legal Practitioner.
In Queensland, such persons can be found by searching: http://www.qld.gov.au/law/legal-mediation-and-justice-ofthe-peace/about-justice-of-the-peace/find-a-justice-of-the-peace/
You will have to find such a person if in a state/territory outside of Queensland. Overseas equivalencies cannot be
accepted.
Declarations from police officers, doctors, chemists, etc. cannot be accepted.
AVELING Queensland White Card Statutory Declaration
Page 1
STATUTORY DECLARATION
Commonwealth Statutory Declaration Act 1959
PART 1: PARTICIPANT DECLARATION
I, ________________________________________________________________________________
(Given name and family name)
of _______________________________________________________________________________
(Residential address)
in the state/territory of ______________________________________
(state/territory)
make the following declaration under the Commonwealth Statutory Declaration Act:
1. I have identified myself truthfully for the course CPCCOHS1001A: Work safely in the
construction industry (White Card)
2. The work submitted during the course was my own work
3. I have received no assistance from anyone else (other than the trainer of the course) in the
completion of an assessment
4. The username and password I used to access the course are:
PART 1
Username: _____________________________ Password: _____________________________
I understand that a person who intentionally makes a false statement in a statutory declaration is guilty
of an offence under section 11 of the Statutory Declarations Act 1959, and I believe that the statements
in this declaration are true in every particular.
Date completed course: ______________ Time taken to complete course: ________________ hours
Location course was taken in: ____________________________________________________
(Town and state/territory)
Note: You MUST sign the declaration in front of an Authorised Person being either a: Justice of the
Peace, Commissioner for Declarations, or, Legal Practitioner (further details on page 1):
Taken and declared before me at: ____________________________________
(Location)
this _____________ month: ________________ year: _______________________________
(date of the month)
___________________________________
(Name of Authorised Person)
___________________________________
(Qualification)
___________________________________
(Signature of Authorised Person)
AVELING Queensland White Card Statutory Declaration
Page 2
PART 2: WITNESS DECLARATION
I, ________________________________________________________________________________
(Witness given name and family name)
of _______________________________________________________________________________
(Witness residential address)
PART 2
in the state/territory of ______________________________ Telephone number __________________
Declare that:
• I am over the age of 18 years and that I am not related to the course participant by blood or
marriage
• I, as the witness, observed the course participant (named in Part 1) undertaking the course
assessment for CPCCOHS1001A: Work safely in the construction industry (White Card)
• That the course participant is one and the same person as the person who undertook the course
assessment on the said date and location of the assessment
• The mode of course assessment undertaken was online
• The residential address of the declarant is correct
• I, as the declarant, know that it is an offence to make the declaration should it be false in any
material particular.
and I make this declaration conscientiously believing the above to be true.
___________________________________
___________________________________
(Witness signature)
(Date)
PART 3: PARTICIPANT SIGNATURE
PART 3
1. Please clearly sign your name in the box below. AVELING will scan or transpose it onto the back
of your Queensland White Card, as required by the Department of Justice and Attorney General.
(Participant sign above – keep your signature within the box)
AVELING Queensland White Card Statutory Declaration
Page 3
PART 4: CERTIFIED COPY OF PROOF OF IDENTIFICATION
A Justice of the Peace, or, Commissioner for Declarations, or, a Legal Practitioner
(Authorised Person)** must sight an original proof of identification document, being either:
•
•
•
•
A current and valid driver's licence issued by an Australian State or Territory, or
A current and valid passport, or
An 18 plus card, or
A school identity card
The Justice of the Peace, or, Commissioner for Declarations, or, a Legal Practitioner must then certify a
copy of the identification, with the words:
“This is to certify this is a true copy of the original document which I have sighted.” (See the example
below.)
PART 4
EXAMPLE OF CERTIFIED PHOTO IDENTIFICATION
** Finding an Authorised Person.
In Queensland, Authorised Persons can be found by searching: http://www.qld.gov.au/law/legal-mediationand-justice-of-the-peace/about-justice-of-the-peace/find-a-justice-of-the-peace/. You will have to find an
equivalent if in a state/territory outside of Queensland. Overseas equivalencies cannot be accepted.
Declarations from police officers, doctors, chemists, etc. cannot be accepted.
AVELING Queensland White Card Statutory Declaration
Page 4