Untuk pemohon Surat Keterangan Catatan Kepolisian  (SKCK) harus memenuhi persyaratan yang telah ditentukan sebagai berikut :

1. Mengisi dan menandatangani daftar pertanyaan yang telah disediakan dan dilampiri dengan :
    a. Fotocopy SKCK atau SKKB yang pernah diperoleh dari Polri (bila ada).
    b. Fotocopy KTP atau SIM Indonesia.
    c. Fotocopy Paspor yang masih berlaku.
    d. Fotocopy Akte Kelahiran atau Surat Kenal Lahir.
    e. Fotocopy Kartu Keluarga.
    f. Fotocopy Surat Nikah/Kawin (bagi yang masih terikat perkawinan).
    g. Fotocopy Surat Ganti Nama (bagi yang pernah berganti nama).
    h. Pasfoto 4 x 6 berfwarna tampak muka dan kedua telinga sebanyak 3 (tiga) lembar.
    i. Sidik Jari dan tanda tangan yang disahkan oleh kepolisian setempat.
    j. Amplop yang disertai dengan perangko balasan.

2. Mengirimkan semua persyaratan ke :

    KEDUTAAN BESAR REPUBLIK INDONESIA
    KANTOR SLO POLRI
    8 Darwin Ave, Yarralumla, ACT 2600 Australia.
    Telp : (02) 62508625, 62508660, Fax : (02) 62771034 

KEDUTAAN BESAR REPUBLIK INDONESIA
EMBASSY OF THE REPUBLIC OF INDONESIA
8 Darwin Avenue, Yarralumla, Canberra, A.C.T. 2600
AUSTRALIA

DAFTAR PERTANYAAN UNTUK PERMOHONAN
 SURAT KETERANGAN CATATAN KEPOLISIAN (SKCK).

Yang bertanda tangan dibawah ini

a. N a m a                              : ..................................................................................................
b. Tempat/Tgl Lahir                : ..................................................................................................
c. Agama                               : ..................................................................................................
d. Kebangsaan                       :...................................................................................................
e. Jenis Kelamin                     : ..................................................................................................
f.  Kawin/Tidak Kawin          : ...................................................................................................
g. Pekerjaan                          : ..................................................................................................
h. Alamat sekarang                : ..................................................................................................
i. Alamat di Indonesia            : ..................................................................................................
j.  Nomor KTP atau SIM Indonesia : .......................................................................................
k. Nomor Telepon/Mobilephone yang bisa dihubungi : .............................................................

Memberikan keterangan / jawaban sebagai berikut :

I.  Hubungan Kekeluargaan

   1. Istri/Suami

       a. N a m a                      : .................................................................................................
       b. Umur                         : .................................................................................................
       c. Agama                       : .................................................................................................
       d. Kebangsaan               : .................................................................................................
       e. Pekerjaan                  : .................................................................................................
       f.  Pendidikan                : .................................................................................................
       g. Alamat                      : .................................................................................................
       h. Orpol/Ormas            : .................................................................................................
           yg diikuti

   2. Ayah kandung

      a. N a m a                     : ..................................................................................................
      b. Umur                        : ..................................................................................................
      c. Agama                      : ..................................................................................................
      d. Kebangsaan             : ...................................................................................................
      e. Pekerjaan                 : ...................................................................................................
      f.  Pendidikan               : ...................................................................................................
      g. Alamat                     : ...................................................................................................
      h. Orpol/Ormas            : ..................................................................................................
          yang diikuti           
 
  3. Ibu  kandung

      a.  N a m a                   : ...................................................................................................
      b. Umur                        : ..................................................................................................
      c. Agama                      : ..................................................................................................
      d. Kebangsaan             : ...................................................................................................
      e. Pekerjaan                 : ...................................................................................................
      f.  Pendidikan               : ...................................................................................................
      g. Alamat                     : ...................................................................................................
      h. Orpol/Ormas            : ..................................................................................................
          yang diikuti 

  4.  Saudara sekandung (Nama, Umur, Pekerjaan, Alamat)

     a. .......................................................................................................................................
         .......................................................................................................................................
     b. ......................................................................................................................................
         ......................................................................................................................................
     c. ......................................................................................................................................
         ......................................................................................................................................

II. Pendidikan di dalam dan luar negeri (nama sekolah, di negara mana, mulai thn s/d thn,
     sponsor)

    1. SD (atau sederajat)                  : ......................................................................................
                                                         ......................................................................................
    2. SMP (atau sederajat)               : ......................................................................................
                                                         ......................................................................................
    3. SMA (atau sederajat)              : ......................................................................................
                                                         .....................................................................................
    4. Akademi (atau sederajat)        :  .....................................................................................
                                                         .....................................................................................
    5. Perguruan Tinggi                     : ......................................................................................
                                                         .....................................................................................
    6. Kursus-kursus                        :  .....................................................................................
                                                         .....................................................................................
                                                         ....................................................................................
                                                         .....................................................................................

III. Riwayat pekerjaan di dalam dan luar negeri (nama pekerjaan, di negara, mulai thn s/d thn,
       sponsor.

    1. ........................................................................................................................................
        ........................................................................................................................................
    2. ........................................................................................................................................
        ........................................................................................................................................

IV. Kunjungan  ke luar negeri  selain  tersebut  pada  point II  dan  III  di atas  (negara yang
      dikunjungi, maksud kunjungan, kapan, sponsor).

    1. ..........................................................................................................................................
        ..........................................................................................................................................
    2. ..........................................................................................................................................
        ..........................................................................................................................................

 V. Kapan anda terakhir kali meninggalkan wilayah Indonesia?

     ..........................................................................................................................................

VI. Pernahkan tersangkut perkara pidana, ya , tidak.  Kalau "ya" jelaskan :

      1. Dalam perkara apa ? .....................................................................................................
      2. Pada tingkat/proses apa? ..............................................................................................
      3. Vonis hakim .................................................................................................................

VII. Keanggotaan dalam organisasi politik/Organisasi massa (nama organisasi, tujuan organisasi,
         jabatan dalam organisasi)

    1. .......................................................................................................................................
        ......................................................................................................................................
    2. ......................................................................................................................................
        ......................................................................................................................................

VIII. Waktu terjadinya peristiwa G.30.S/PKI dimana Anda bertempat tinggal dan bekerja?

Jelaskan           : .....................................................................................................................
                          .....................................................................................................................

Serta dari mana anda tahu adanya G.30.S/PKI?

Jelaskan          : .......................................................................................................................
                        .......................................................................................................................

IX. Ciri-ciri badan

    1. Rambut                : .........................................................................................................
    2. Muka                  : .........................................................................................................
    3. Kulit                    : ........................................................................................................
    4. Tinggi                  : ........................................................................................................
    5. Perawakan          : ........................................................................................................
    6. Tanda-tanda istimewa : ................................................................................................
    7. Lain-lain             : ........................................................................................................

X. Untuk keperluan apa Surat Keterangan Catatan Kepolisian (SKCK) saudara butuhkan?

Jelaskan         : ......................................................................................................................

Keterangan di atas saya buat dengan sebenarnya atas sumpah menurut kepercayaan saya. Apabila dikemudian hari ternyata keterangan ini tidak benar maka saya akan dituntut berdasarkan hukum yang berlaku.