YOU MUST COMPLETE ALL SECTIONS OF

THIS FORM & RETURN IT IN GOOD QUALITY

Upload to our website: http://www.eot.edu.au/account , OR

Return by Post: 813/1 Abel Place, Cronulla, NSW, AUS, 2230

FORM30001
UCA532063
STD81795

Statutory Declaration: Commonwealth Statutory Declaration Act 1959

Note: A person who intentionally makes a false statement in a statutory declaration is guilty of an offence, the punishment for which
is imprisonment for a term of 4 years see section 11 of the Statutory Declarations Act 1959.

Section 1: Applicant
I, Esteban Calderon, of 2A Shipley Place Westminster in the state of WA, 6061 make the following declaration under the Commonwealth
Statutory Declaration Act 1959 and so solemnly and sincerely declare that:
1. The work submitted for the White Card course was my own work.
2. I have received no assistance from anyone (course trainer excluded) in the completion of the White Card course assessment.
3. I have identified myself truthfully for the White Card course undertaken
4. The time, date, place, and the number of the hours taken by me to complete the online course and assessment is:
10 hrs hours
a. Time taken to complete course: ______________
25/11/2014
b. Date course was completed: _______________
Shipley Place Westminster 6061
c. Place course was completed (address or physical location): 2A
_________________________________________________

I make this solemn and sincere declaration conscientiously believing the same to be true, and 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 Commonwealth
Statutory Declaration Act 1959, AND I believe that the statements in this declaration are true in every particular.
___________________________________________________________
Signature of Applicant (SIGN IN FRONT OF AN AUTHORISED PERSON)

__________________
Date

Section 2: Authorised Person

For details please see the find an Authorised Person to Certify Your Documents section on Page 2.
Taken and declared before me at ____________________________________________________ this ________ day of the month of
______________________, 20________
_______________________________________ (Name)
_______________________________________ (Address)
_______________________________________
Stamp Here

_______________________________________ (Qualification)

Signature

Section 3: Observer (Any person who witnessed you undertaking the online assessment)
I, ____________________________________ (Name), of _____________________________________________________________
___________________________ (Address) in the state of___________ postcode________, contact phone number ______________
Do solemnly and sincerely declare that I am over the age of 18 years and that:
1.
2.
3.

I have observed the course participant undertaking the course assessment and the mode of assessment was undertaken online.
I confirm that the course participant is one and the same person as the person who undertook the course assessment on the
said time, date and place stated in the Applicants declaration above.
I know that it is an offence to make the declaration should it be false in any material particular and I believe that the statements
made in this declaration are true in every particular.

_________________________________________________________
Signature of declarant/deponent (the Observer)

Section 4: Certified Copy of Identification

Provide a certified copy of photo Identification See page 2 for details.

__________________
Date

PAGE 2 DO NOT RETURN THIS PAGE

Important information

Instructions
You must return BOTH the Statutory Declaration, AND a
Certified Copy of Your Identification.
You can return these by either uploading them to our
website at http://www.eot.edu.au/account OR by posting
them 813/1 Abel Place, Cronulla, NSW, AUS, 2230 (Please do
NOT use Registered Post).

Statutory Declaration
ALL sections of this form must be completed and returned on
one (1) page.
Section 1 is to be completed by the student, and signed in
front of an authorised person, who will then complete
section 2 and may also certify your identification documents.

Find an Authorised Person to

Certify Your Documents
Only certain people are authorised to certify identification
documents. Many of these are listed below:
1.

Section 3 must be completed by a person who has observed

you participating in your online assessment.

Certified Copy of Identification

Acceptable Identification Documents
Express Online Training will accept a certified copy of one (1)
photographic identification document such as:

a current and valid drivers licence issued by an

Australian state or territory
an 18 plus card
a current and valid passport
a school identity card

How to Certify a Documents

What is a certified copy?
A certified copy is a copy of an original identification
document, which has been certified and signed by a person
who is authorised to certify that it is a true and correct copy
of the original.

How do I obtain a certified copy?

You will need to take your original document(s) and a clear
photocopy of both sides of the original document to a person
who is authorised to certify proof of identity documents.

The certification must be on the copy of the document,

not on a separate page attached to the document.
If any documents are written in a language other than
English, they must be accompanied by an English
translation prepared by an accredited translator.
Documents certified more than 12 months ago will not
be accepted.

2.

A person who is currently licensed or registered under a

law of a State or Territory to practise in one of the
following occupations:
a. Chiropractor
b. Dentist
c. Legal practitioner
d. Medical practitioner
e. Nurse
f. Optometrist
g. Patent attorney
h. Pharmacist
i. Physiotherapist
j. Psychologist
k. Trade marks attorney
l. Veterinary surgeon
One of the following persons:
a. Justice of the Peace
b. Teacher employed on a full-time basis at a
school or tertiary education institution
c. Agent of the Australian Postal Corporation
who is in charge of, or a permanent employee
with two or more years of continuous service
with, an office supplying postal services to the
public
d. Notary public
e. Police officer

Example of a Certified Document

How is a document certified?

The authorised person will need to:
1.
2.

Sight the original document and the copy to ensure that

both documents are identical,
Write or stamp this is a true and correct copy of the
original document I have sighted or certified true
copy, followed by their:
a. signature
b. printed name
c. qualification and date

PAGE 2 DO NOT RETURN THIS PAGE