Form 51 – Corrective Services Act 2006
Version 5
Form 51
QUEENSLAND
Corrective Services Act 2006(s. 190)
LEAVE TO APPEAR OR BE REPRESENTED BY AN AGENT
BEFORE PAROLE BOARD QUEENSLAND
Prisoner: / [name of prisoner]Date of Birth: / [insert DOB] / Identification Number: [insert ID number]
Location: / [insert facility that prisoner is currently accomodated in]
To the Secretariat of Parole Board Queensland.
I, the above named prisoner, seek the leave of the Board to
*appear before Parole Board Queenslandor
*be represented by an agent before Parole Board Queensland
in relation to my application for a parole order.
*Delete whichever is inapplicable
The name and address of my agent is:
Name: [insert name of agent]
Address: [insert agent' s address]
Telephone Number: [insert agent's telephone number]
Information in support of this application: [insert relevant information]
I have attached the further supporting information in relation to my nominated agent.
Signature of Prisoner: ______
Date:
Privacy Statement
QueenslandCorrective Services is collecting the information on this form to consider and determine the applicants request for representation by an agent under Sections 190 and 341 of the Corrective Services Act2006.
Queensland Corrective Services usually gives some or all of this information to the Queensland Police Service or other State, interstate, Commonwealth and international government departments or other entities; to private organisations which provide services to offenders and, in some circumstances, to individuals.
Supporting Information for Application to Be Represented by Agent (to be completed by the nominated agent)
If you have applied, or been nominated, to appear before Parole Board Queensland in support of a prisoner’s parole application you are requested to provide the following information. The information you provide will be used by theParole Board to determine whether to grant leave for you to appear in support of the prisoner’s parole application.
If you require more space to respond to the questions please attach a separate document.
What is your relationship to the prisoner?(For example: family member, friend, or a professional relationship such as counsellor and client)
Please provide details of your level of education, qualifications and experience.
Are you a member of any professional bodies that require members to comply with a code of conduct?(A code of conduct refers to expected standards of behaviour of members of a professional body. A code of conduct would usually include a requirement to act honestly, with integrity and in accordance with accepted professional standards).
Do you have any convictions recorded against you for an indictable offence or an offence of dishonesty? If yes, please provide details.
(A conviction is a finding of guilt, or the acceptance of a plea of guilty, by a court. An indictable offence is an offence that is tried before a court other than a court exercising summary jurisdiction- an indictable offence is usually tried in the District or Supreme Court. An offence of dishonesty means an offence involving fraud, deception, misappropriation, assuming a false identity or the making of false statements).
Are you currently subject to disciplinary or criminal proceedings? If yes, please provide details.
What fees do your propose to charge the prisoner for representing them?
Signature of Agent: ______
Name of Agent:______
Name of Prisoner:______
Date: