Information you provide on this form will be used to assist the Department of Corrective
Services to provide you with relevant information and will be treated in the STRICTEST
OF CONFIDENCE. Please ensure that all the questions are completed as fully as possible
before submitting it.
The registrar will normally communicate with you in writing. If this is not
suitable, or if you have special needs, please indicate below whether you would
like an officer to contact you to discuss this further.
Relation to victim
If no, please provide details of the victim and your relationship to that person below.
Details of offence and offender
Fill out as much information as you can (if unknown leave blank).
Name of the offender/s
Alternative contact person or agent
Please nominate another contact person who is likely to know your whereabouts, in
case the Department of Corrective Services 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 agent.
Please note: By answering Yes to this question, you are instructing the Registrar
to correspond with this person only. You (the victim) will not be contacted directly.