Department of the Attorney-General and Justice

www.justice.nt.gov.au

DEPARTMENT OF JUSTICE	www.justice.nt.gov.au

NORTHERN TERRITORY VICTIMS REGISTER Application Form
Information you provide will remain confidential and will only be held on the Victims Register. Access to this
information is limited to staff with a genuine and essential need to have such access and will not be available to offenders or other persons.

1.	Details of the person wishing to apply for registration (if you are not the direct Victim please complete section 2)

Title (Mr, Mrs, Ms, Miss)	Date of Birth		
Surname	Given names		
Principal telephone number

Previous names (e.g. maiden name, change of name for privacy)	Alternative phone (mobile/work)		
Postal Address	State	Postcode	
Street Address	State	Postcode	

Gender

□ Male	□ Female

Are you and Aboriginal and/or a Torres Strait Islander
□ Yes	□ No

2.	Details of the Victim	(If you are not the direct victim of crime, please provide details of the victim of the crime and your
relationship to that person here)	
Title (Mr, Mrs, Ms, Miss)	Date of Birth	
Surname	Given names	

Previous names (e.g. maiden name, change of name for privacy reasons)	
Your relationship to the Victim (e.g. mother, uncle, aunt, ex-spouse, de-facto, friend, partner, work associate, counsellor, you may be requested to provide evidence of your relationship to the victim)	
Gender
□ Male	□ Female	Are you and Aboriginal and/or a Torres Strait Islander
□ Yes	□ No	

3.	Details of the Offender and offence	
Offender 1	
Title (Mr, Mrs, Ms, Miss)	Date of Birth	
Surname	Given names	
Also known as / Aliases	DPP Case #	
Details on Sentencing Imposed	Date of conviction	
Details/Nature of offence/s	Date of offence	
	Name of Court	
	Gender
□ Male	□ Female	

Offender 2	
Title (Mr, Mrs, Ms, Miss)	Date of Birth	
Surname	Given names	
Also known as / Aliases	DPP Case #	
Details on Sentencing Imposed	Date of conviction	
Details/Nature of offence/s

Please add details of other offender(s), if any, on the back of this form or a separate sheet attached to this registration form.	Date of offence	
	Name of Court	
	Gender
□ Male	□ Female	

5.	Nominee (Please only complete this section if you would like to nominate another person or agency to receive information of your behalf)	

Please nominate another contact person who is likely to know your whereabouts, in case the Department of Justice is unable to contact you.  Information about the nature of the call will not be disclosed to this person unless you authorise for them to act as your nominee.

Would you like this alternative contact person to act as your nominee and receive information on your behalf;
(please circle)                                 YES                     NO

Please note: By answering YES to this question, you are instructing the CVSU to correspond with this person only. You (the Victim) will not be contacted directly.	
Title (Mr, Mrs, Ms, Miss)	Date of Birth		
Surname	Given names		
Principal telephone number	Alternative phone (mobile/work)		

Previous names (e.g. maiden name, change of name for privacy)	
Your relationship to the Victim		
Postal Address	State	Postcode	
Street Address	State	Postcode	
Gender
□ Male	□ Female	Are you and Aboriginal and/or a Torres Strait Islander
□ Yes	□ No	
The person nominated here must agree to sign Section 7 on the last page regarding Confidentiality.	

6.	Proof of Identity

Every application must be accompanied by proof of the applicant’s identity.
Please indicate which document you have attached to this application (only one is required):

□	Current Australian Drivers Licence

□	Birth Certificate

□	Current Passport

□	Other (please specify)

Do not send originals, a clear readable copy will be sufficient.

7.	Confidentiality

You must sign this section.

I/We request that my/our details be entered onto the Victims Register, operated by the Crime Victims Services
Unit, Department of Justice, until such time as I/we notify in writing that I/we wish my/our details to be removed.

I/We understand and accept that the information supplied through the Victims Register is confidential.  I/We agree not to release this information for the purpose of public dissemination without approval from the Department.  I/We agree not to use this information for any unlawful purpose which could cause harm or detriment to any person.

I/we understand and accept that if I/we choose not to provide my home address, or fail to advise of a change of address, that the Department may not be able to provide a complete service.

Please note that section 29 of the Victims of Crime Rights and Services Act 2006 provides for financial and/or imprisonment penalties for breaches of confidentiality.

Signature of Applicant:   	

Date:   	_/ 	/ 	

Signature of Nominee:   	
(if required)

Date:   	_/ 	/ 	

Please send the completed form to:

NT Victims Register Coordinator Crime Victims Services Unit Department of Justice
GPO Box 1722
DARWIN	NT  0800

Please mark the envelope:  "Private and Confidential"

If you have any questions about completing this form or the function of the Victims Register please phone the
Crime Victims Services Unit (CVSU) on 1800 221 372 or email victims.register@nt.gov.au.

ADDITIONAL INFORMATION !if necessary!