VERSION 4 FORM 28 QUEENSLAND CORRECTIVE SERVICES ACT 2006

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Form 28 - Application by Prisoner for Exceptional Circumstances Parole Order - Version 2

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:      


VERSION 4 FORM 28 QUEENSLAND CORRECTIVE SERVICES ACT 2006


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]


VERSION 4 FORM 28 QUEENSLAND CORRECTIVE SERVICES ACT 2006


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.


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