Version 4
Form 28
QUEENSLAND
Corrective Services Act 2006 (s. 176)
APPLICATION BY PRISONER FOR
EXCEPTIONAL CIRCUMSTANCES PAROLE ORDER
Prisoner: |
[name of prisoner] |
|
Date of Birth: |
[insert DOB] |
Identification Number: [insert ID number] |
Location: |
[insert current correctional centre] |
I, the above named prisoner, apply to Parole Board Queensland for release on an exceptional circumstances parole order.
Signature of Prisoner: ________________
Date:
PERSONAL PARTICULARS
Marital Status: [insert marital status]
Address of nominated accommodation: [insert address]
Name of primary resident: [insert occupiers name]
Primary resident Telephone: [home number] (Home) [mobile number] (Mobile)
Primary resident email address: [email address]
Relationship to primary resident: [eg. wife, husband, de-facto, friend]
If applicable, advise name and address of future employer: [insert details]
EVIDENCE AND ADDITIONAL INFORMATION SUPPORTING REQUEST FOR RELEASE UNDER EXCEPTIONAL CIRCUMSTANCES MUST BE ATTACHED
Privacy Statement
Queensland Corrective Services is collecting the information on this form so that the Parole Board Queensland may hear and decide a prisoner’s application for a parole order under Sections 176, 263 and 341 of the Corrective Services Act 2006.
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.
CLI SPECIAL DIRECTIVES PRINT CLI VERSION
der Universität Zürich (uzh) Version xx mai 2012
DIGIT EPREDMETI VERSION 10 01082008
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