Aboriginal and Torres Strait Islander Basic Paediatric Training Affirmative Pathway

Statutory Declaration of Aboriginal and/or Torres Strait Islander status

Statutory Declaration – Oaths Act 1867 (Qld)

I, ______________________________________________________ (full name)

If you are also known by other name - i.e. maiden name, community or traditional name

________________________________________________________________________

of________________________________________________________________(address)

do solemnly and sincerely declare that (tick all that apply):

☐ I am of Aboriginal descent

☐ I am of Torres Strait Islander descent

and I make this solemn declaration conscientiously believing the same to be true and by virtue of the provisions of the Oaths Act 1867.

I understand that it is an offence under the Criminal Code Act 1899 to make false declaration.

Signature of person making a declaration
Declared at (place)
on (day)
of (month and year)
Before me (signature of person before whom the declaration is made)
Full name, qualification and address of person before whom the declaration is made, in accordance with s13 of the Oaths Act 1867 (Qld) (in printed letters)