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Collects applicant identity and contact details, including family/surname, given names, aliases, date and place of birth, sex, driver’s licence number, business contact number, mobile number, and email address. Also requests permanent residential addresses for the last ten years with full location details and guidance for overseas addresses when dates are unavailable. 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Either type in the fields provided or print this form and complete it using a pen and BLOCK LETTERS. Tick where applicable 3   \n\n| Personal details |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Family / Surname (current) |  |  | Given names  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |\n| All other names you have been known by |  |  |  |  |  |  |  |  |  |  |\n| Date of birth / / | Place of birth | State / Country of birth |  | Sex\u003Cbr>Male |  | Female |  | Indeterminate / Intersex / Unspecified |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |\n| Drivers licence number |  | State | Contact number (business hours) |  |  |  |  |  | Mobile number |  |\n| Email address |  |  |  |  |  |  |  |  |  |  |\n\n| Permanent residential addresses over the last ten years |  |\n| --- | --- |\n| \u003Cbr>Addresses | Period of residence\u003Cbr>|\n| Full details of all addresses (including postcode) are required, including overseas addresses | If actual dates are unavailable, list years of residence. |\n|  | to |\n|  | to |\n|  | to |\n|  | to |\n|  | to |\n|  | to |\n|  | to |\n|  | to |\n|  | to |\n|  | to |\n| If insufficient space, attach additional details |  |\n\n| Criminal / Traffic charge, conviction or pecuniary penalties |\n| --- |\n| (i) Are you the subject of any traffic violations, criminal or traffic charge(s) still pending before a court?  |\n| No  Yes  If Yes provide details (If insufficient space, attach additional details) |\n| (ii) Do you have any conviction(s) or finding(s) of guilt which are less than ten (10) years old, or any juvenile conviction(s) or finding(s) of guilt which are less than five (5) years old?\u003Cbr>No  Yes  If Yes provide details (If insufficient space, attach additional details) |\n| (iii) Do you have any conviction(s) or finding(s) of guilt which are over ten (10) years old,(or five (5) years for juvenile conviction(s) or finding(s) of guilt) where the sentence imposed was greater than thirty (30) months imprisonment?\u003Cbr>No  Yes  If Yes provide details (If insufficient space, attach additional details) |\n\nSENSITIVE: PERSONAL ONCE COMPLETED B195 (Design date 09/19)– Page 1","cbCaioZgJvAX0w6p","https://ap.wps.com/l/cbCaioZgJvAX0w6p","pdf",628841,"English","# Personal details\n## Identification and contact information\n## Permanent residential addresses (last ten years)\n## Criminal / Traffic charge, conviction or pecuniary penalties","[{\"question\":\"What personal details are requested in this form section?\",\"answer\":\"It asks for family/surname, given names, any other names, date and place of birth, sex, driver’s licence number, business contact number, mobile number, and email address.\"},{\"question\":\"How are permanent residential addresses over the last ten years recorded?\",\"answer\":\"Applicants provide full address details (including postcode) for each residence period, including overseas addresses, and can list years of residence if exact dates are unavailable.\"},{\"question\":\"What criminal or traffic information must be disclosed?\",\"answer\":\"The form asks whether there are any pending traffic violations or criminal charges, and whether there are convictions or findings of guilt within specific time windows, plus details when “Yes” is selected.\"}]","Customs Broker Licence Application - Personal Information | PDF",1790424641]