Form
Personal particulars for assessment
including character assessment
Important – Please read this information carefully before you
complete this form. Once you have completed this form we
strongly advise that you keep a copy for your records.
This form is to be completed in English by applicants who are
16 years of age or over, as requested by the office processing the
application.
Please use a pen, and write neatly in English using BLOCK LETTERS.
Tick where applicable 3
If you need more space for any answers, give details at Part T –
Additional information
Integrity of application
The Department of Immigration and Border Protection (the
department) is committed to maintaining the integrity of the visa
and citizenship programs. Please be aware that if you provide us
with fraudulent documents or claims, this may result in
processing delays and possibly your application being refused.
80
Part A – Applicant details
1
Important information about privacy
Your personal information is protected by law, including the
Privacy Act 1988. Important information about the collection,
use and disclosure (to other agencies and third parties, including
overseas entities) of your personal information, including
sensitive information, is contained in form 1442i Privacy notice.
Form 1442i is available from the department’s website
www.border.gov.au/allforms/ or offices of the department.
You should ensure that you read and understand form 1442i
before completing this form.
Please provide your details as they appear in your official documents.
For example, passport, identity document, travel document, birth
certificate.
Note: If you have one name only, please write it in the ‘Family name’
field.
Family name
All given names
Sex
Female
Male
Day
Month
Year
Day, month and year
MUST be provided
Date of birth
Suburb of birth
Town/City of birth
State/Province/Region
Country
2
Do you ever use a Chinese Commercial Code Number for your names
shown in the passport/travel document at Question 1?
No
Yes
3
Chinese Commercial Code Number (in full)
Are you of Russian descent?
No
Yes
© COMMONWEALTH OF AUSTRALIA, 2015
In English, provide your patronymic name
80 (Design date 10/15) - Page 1
4
Part B – Passport / Travel document
details
Have you been known by any other name(s)? Include:
•
•
•
•
name at birth
name before or after marriage
adoptive or foster name
alias or pseudonym
• cultural or tribal name or
clan/subclan name
• preferred name
• other spellings of names
No
Yes
9
Do you have a current passport or travel document?
No
Go to Question 13
Yes
Give details
Passport/travel document number
Give details in English
Type of name
Family name
Country of passport/travel document
Given names
Day
Month
Year
Date of issue
Is this the original issue date?
5
If more than one name, give details at Part T – Additional information
No
Have you ever had a different date of birth to the one shown at
Question 1?
Yes
No
Yes
6
Day
Month
Day
Year
Different date of birth
Day
Nationality
No, I am stateless
Place of issue/issuing authority
Give details
Month
Year
Date you gained this citizenship
Do you hold or have you held citizenship from any other country
(including dual citizenships and all previous citizenships)?
No
Country
How did you gain this citizenship (eg. birth, descent,
naturalisation)?
When did you have this citizenship?
Day
Month
From
Year
Day
Month
Year
to
Note: If you still have the citizenship, write ‘CURRENT’.
If more than one country, give details at Part T – Additional
information
Do you currently have permanent residency rights in any country other
than those declared in Questions 6 or 7?
No
Yes
List all other countries
80 (Design date 10/15) - Page 2
Year
Year
Name on the document (if the same as Question 1, write ‘SAME AS
QUESTION 1’)
Family name
How did you gain this citizenship (eg. birth, descent,
naturalisation)?
Day
Yes
Month
Date of expiry
Given names
8
Month
Do you currently have citizenship from any country?
Yes
7
Give original issue date
© COMMONWEALTH OF AUSTRALIA, 2015
10 Do you have any other current passport or travel document?
13 Do you have, or remember, any of the document details?
No
No
Yes
Give details
Passport/travel document number
Yes
Give as much information as possible
Passport/travel document number
Country of passport/travel document
Country of passport/travel document
Day
Month
Day
Year
Month
Year
Date of issue
Date of issue
Date of expiry
Date of expiry
Nationality
Nationality
Place of issue/issuing authority
Place of issue/issuing authority
Name on the document (if the same as Question 1, write ‘SAME AS
QUESTION 1’)
Family name
Name on the document (if the same as Question 1, write ‘SAME AS
QUESTION 1’)
Family name
Given names
Given names
11 Have you ever had any previous passports or travel documents
(including expired, lost or stolen documents)?
No
Go to Part C
14 Do you currently have, or have you ever had, any national identity
Yes
12 What happened to this document (Tick one only)
Expired
documents or numbers (including birth registration numbers, social
security cards etc)?
No
Yes
Lost/stolen
Other
Part C – Identity documents
Give details
Give details
Type of identification
document
© COMMONWEALTH OF AUSTRALIA, 2015
Country of issue
Identification number
shown (if applicable)
80 (Design date 10/15) - Page 3
Part D – Address and contact details
15 Do you have any email addresses?
16 Do you have current contact telephone numbers?
Note: Include all personal, student and work email addresses. Do not
include migration agent email addresses.
No
No
Yes
Provide all telephone numbers
Country code
Provide all of your email addresses
Yes
Area code
Number
Work
(
) (
)
Home
(
) (
)
Mobile/cell
Other
17 Your address history for the last 10 years.
Note: If you are applying for a refugee/humanitarian visa, you must provide all addresses for the last 30 years.
Include:
• addresses inside and outside Australia
• places you resided for study/work
• refugee camps
• any other place you have resided such as share houses, university residences and temporary accommodation.
Note: Provide your address history in chronological order with no gaps in the timeline. If there are gaps, you must provide an explanation at Part T –
Additional information.
Date from
Month
Date to
Year
Month
Full address (house number, street name, suburb, town/city, postcode)
Country
Year
CURRENT
Part E – International travel / movements
18 Have you travelled to any country other than Australia in the last 10 years?
Note: If you are applying for a refugee/humanitarian visa, you must provide all visits to any country other than Australia for the last 30 years.
Include:
• work or study outside your usual country of residence
• holiday/leisure trips
• business
• military deployment
• visits back to your own country.
No
Yes
Give details in chronological order
Date from
Day
Month
80 (Design date 10/15) - Page 4
Date to
Year
Day
Month
Reason for visit
Year
© COMMONWEALTH OF AUSTRALIA, 2015
Country
Part F – Employment
19 Give details of all employment and unemployment
Employment includes:
Unemployment includes:
• all paid employment
• from date of birth up until first employment
• self-employment/family business
• all gaps/breaks between employment
• work experience/internships
• all gaps between education.
• unpaid employment/volunteer work.
If you are currently retired – write ‘CURRENTLY RETIRED’ in ‘Name of business’ field and provide details in the ‘Your occupation and duties’ field.
If you have never worked – write your date of birth in the ‘Date from’ field and ‘NEVER WORKED’ in the ‘Name of business/company’ field and provide details in the ‘Your occupation and duties’ field.
Note: Provide your employment and unemployment history with no gaps in the timeline. If there are gaps, you must provide an explanation at Part T – Additional information.
Date from
Month
Year
Date to
Month
Year
Name of business/company
(no abbreviations)
Type of business
(eg. government
department, bakery)
Your occupation and duties
OR
If unemployed/retired/never worked,
provide details of how you occupied your time
and financially supported yourself
Full address of business/company
(Building number, street name, suburb,
town/city, state/province)
(no Post Office box)
Country
CURRENT
© COMMONWEALTH OF AUSTRALIA, 2015
80 (Design date 10/15) - Page 5
Part G – Education
20 Give details of all tertiary education and qualifications
Education/qualifications includes:
• college/vocational schools
• specialist training
• university
• skill/trade qualifications.
• research/thesis
Note: If you are applying for a Refugee and Humanitarian visa, you must provide details of all education and qualifications since birth.
Date from
Month
Year
Date to
Month
Year
Full name of institution
(no abbreviations)
Full name of course or description of research/
Thesis and supervisor details (no abbreviations)
Course status
Completed
Withdrew
Currently enrolled
Completed
Withdrew
Currently enrolled
Completed
Withdrew
Currently enrolled
Completed
Withdrew
Currently enrolled
Completed
Withdrew
Currently enrolled
Completed
Withdrew
Currently enrolled
Completed
Withdrew
Currently enrolled
Completed
Withdrew
Currently enrolled
80 (Design date 10/15) - Page 6
© COMMONWEALTH OF AUSTRALIA, 2015
Campus/address of institution
Country
Part H – Proposed travel or further stay
details
21 Are you currently in Australia?
No
Go to Question 25
Yes
Proposed travel
Further stay
22 Why are you travelling to Australia?
25 What is your main reason for remaining in Australia?
Include any relevant dates or events
23 Do you have any proposed or booked travel dates for your journey to
26 List the towns/cities you will visit during your further stay in Australia
Australia?
No
Yes
Give details of proposed arrival in Australia
Day
Month
27 Give details of your arrival in Australia
Year
Day
Arrival date
Month
Year
Arrival date
Flight number or vessel details (if known)
City of arrival
City of arrival
28 Are you applying for a temporary visa?
Give details of countries you will visit on your way to Australia
(write ‘N/A’ if not applicable)
No
Go to Part I
Yes
29 Do you have any proposed or booked travel for your departure from
Australia?
List the towns/cities you will visit during your time in Australia
No
Yes
Give details
Day
Month
Year
Departure date
24 Are you applying for a temporary visa?
Flight number or vessel details (if known)
No
Go to Part I
Yes
Give details of proposed final departure from Australia
Day
Month
Year
Departure date
City of departure
Give details of countries you will visit after your departure from Australia
(write ‘N/A’ if not applicable)
Flight number or vessel details (if known)
City of departure
Give details of countries you will visit after your departure from Australia
(write ‘N/A’ if not applicable)
Now go to Part I
© COMMONWEALTH OF AUSTRALIA, 2015
80 (Design date 10/15) - Page 7
Part I – Address(es) in Australia
30 Are you currently in Australia?
No
Yes
Go to Question 33
Located in Australia
Located outside Australia
31 Do you know any details of the places you will stay during your time in
Australia (eg. hotel, friends, relatives)?
No
Go to Part J
33 Do you have any other addresses in Australia that have not been
declared at Question 17?
No
Yes
Give the residential address and contact numbers
Note: A post office box is not acceptable.
Address (including hotel name and/or unit and building number and
street name)
Go to Part J
Yes
Give the residential address and contact numbers
Address (including hotel name and/or unit and building number and
street name)
Suburb and town/city
Suburb and town/city
State or territory
State or territory
Postcode
Office hours
Office hours
)
(Area code
)
Mobile/cell
When and in what circumstances did you reside, or stay, at this
address?
Mobile/cell
32 Will you stay at any other address?
No
Postcode
Telephone numbers
Telephone numbers
(Area code
Go to Part J
Yes
Give the residential address and contact numbers
Address (including hotel name and/or unit and building number and
street name)
If you have more than one other address in Australia that has not been
declared above or at Question 17, give details at Part T – Additional
information.
Suburb and town/city
State or territory
Postcode
Telephone numbers
Office hours
(Area code
)
Mobile/cell
If you will stay at any other address(es), give details at Part T –
Additional information.
Now go to Part J
80 (Design date 10/15) - Page 8
© COMMONWEALTH OF AUSTRALIA, 2015
Part J – Australian visa history
34 Are you currently in Australia?
No
Yes
Give details of current visa
Type of visa you hold
(eg. visitor, business)
Reason for journey
Name used on entry
Place of visa issue
Arrival date
Day
Month
Year
35 Have you been to Australia before?
No
Yes
Give details of previous visas
Type of visa you held
(eg. visitor, business)
Reason for journey
Name used on entry
Part K – Character
36 Have you, or any other person included in this
application, ever:
• been charged with any offence that is
currently awaiting legal action?
No
Yes
Place of visa issue
Arrival date
Day
Month
Departure date
Year
Day
Month
Year
• served in a military force, police force, state
sponsored/private militia or intelligence
agency (including secret police)?
No
Yes
• undergone any military/paramilitary training,
been trained in weapons/explosives or in the
manufacture of chemical/biological products?
No
Yes
• been involved in people smuggling or people
trafficking offences?
No
Yes
• been convicted of an offence in any country
(including any conviction which is now
removed from official records)?
No
Yes
• been the subject of an arrest warrant or
Interpol notice?
• been removed, deported or excluded from any
country (including Australia)?
No
Yes
No
Yes
• overstayed a visa in any country (including
Australia)?
No
Yes
• had any outstanding debts to the Australian
Government or any public authority in
Australia?
No
Yes
• been found guilty of a sexually based offence
involving a child (including where no
conviction was recorded)?
No
Yes
• been named on a sex offender register?
No
Yes
• been acquitted of any offence on the grounds
of unsoundness of mind or insanity?
No
Yes
• been found by a court not fit to plead?
No
Yes
• been directly or indirectly involved in, or
associated with, activities which would
represent a risk to national security in
Australia or any other country?
No
Yes
• been charged with, or indicted for: genocide,
war crimes, crimes against humanity, torture,
slavery, or any other crime that is otherwise of
a serious international concern?
No
Yes
• been associated with a person, group or
organisation that has been/is involved in
criminal conduct?
No
Yes
• been associated with an organisation engaged
in violence or engaged in acts of violence
(including war, insurgency, freedom fighting,
terrorism, protest) either overseas or in
Australia?
No
Yes
If you answered ‘Yes’ to any of the questions at Question 36, you must
state who it applies to and give ALL relevant details. If the matter relates
to a criminal conviction, please give the nature of the offence, full details
of sentence and dates of any period of imprisonment or other detention.
© COMMONWEALTH OF AUSTRALIA, 2015
80 (Design date 10/15) - Page 9
Part L – Military service
37 Have you undertaken any military service?
Military service includes:
• compulsory
• conscription
• military training
• voluntary
• professional.
No
Yes
Give details in chronological order
Date from
Day
Month
Date to
Year
Day
Month
Country of service
Year
Part M – Employed by intelligence or
security agency
Full name of Unit/
Battalion/Brigade
Country of
deployment
40 Have you ever been excluded, asked to leave, deported or removed from
any country?
officer or an agent of an intelligence or security agency?
No
No
Yes
Give details of dates, countries and circumstances
Give details of organisation, role and dates you served
Part P – Citizenship refusals
Part N – Visa refusals
41 Have you ever been refused, renounced or rescinded citizenship of any
country?
39 Have you ever been refused a visa to any country?
No
No
Yes
Duties
Part O – Deportations
38 Are you currently, or have you been employed as an intelligence
Yes
Rank
Give dates of refusal, countries and circumstances of
refusal
80 (Design date 10/15) - Page 10
Yes
© COMMONWEALTH OF AUSTRALIA, 2015
Give dates of refusal, countries and circumstances of
refusal
Part Q – Associated people
42 Do you have a partner?
Partner includes wife, husband, fiancé, boyfriend, girlfriend, significant other and de facto.
If widowed you must give details for your deceased partner.
No
Yes
Give details
(If not living, write ‘DECEASED’ in ‘Country of current residence’ column)
Relationship to you
Town/City
Family name
Place of birth
State/Province/Region
Given names
(include patronymic name)
Any other names
(eg. maiden or tribal name)
Sex
M/F
Date of birth
Day
Year
Chinese commercial codes
(If not applicable, write ‘N/A’)
Country of current residence
Migrating with you?
(If not living, write ‘DECEASED’)
Citizenship(s) and year granted
Country
Month
No
Yes
43 Do you have children?
Children includes biological or adopted, children from a current or previous marriage, all step-children and deceased children.
No
Yes
Give details
(If not living, write ‘DECEASED’ in ‘Country of current residence’ column)
Child 1
Relationship to you
Town/City
Family name
Place of birth
State/Province/Region
Given names
(include patronymic name)
Any other names
(eg. maiden or tribal name)
Sex
M/F
Date of birth
Day
Year
Chinese commercial codes
(If not applicable, write ‘N/A’)
Country of current residence
Migrating with you?
(If not living, write ‘DECEASED’)
Citizenship(s) and year granted
Country
Month
No
Yes
Child 2
Relationship to you
Town/City
Family name
Place of birth
State/Province/Region
Given names
(include patronymic name)
Country
Any other names
(eg. maiden or tribal name)
Citizenship(s) and year granted
Sex
M/F
Date of birth
Day
Month
Year
Chinese commercial codes
(If not applicable, write ‘N/A’)
Country of current residence
Migrating with you?
(If not living, write ‘DECEASED’)
No
© COMMONWEALTH OF AUSTRALIA, 2015
Yes
80 (Design date 10/15) - Page 11
Child 3
Relationship to you
Town/City
Family name
Place of birth
State/Province/Region
Given names
(include patronymic name)
Any other names
(eg. maiden or tribal name)
Sex
M/F
Date of birth
Day
Year
Chinese commercial codes
(If not applicable, write ‘N/A’)
Country of current residence
Migrating with you?
(If not living, write ‘DECEASED’)
Citizenship(s) and year granted
Country
Month
No
Yes
Child 4
Relationship to you
Town/City
Family name
Place of birth
State/Province/Region
Given names
(include patronymic name)
Any other names
(eg. maiden or tribal name)
Sex
M/F
Date of birth
Day
Year
Chinese commercial codes
(If not applicable, write ‘N/A’)
Country of current residence
Migrating with you?
(If not living, write ‘DECEASED’)
Citizenship(s) and year granted
Country
Month
No
Yes
Child 5
Relationship to you
Town/City
Family name
Place of birth
State/Province/Region
Given names
(include patronymic name)
Any other names
(eg. maiden or tribal name)
Sex
M/F
Date of birth
Day
Year
Country of current residence
Migrating with you?
(If not living, write ‘DECEASED’)
Citizenship(s) and year granted
Country
Month
Chinese commercial codes
(If not applicable, write ‘N/A’)
No
Yes
Child 6
Relationship to you
Town/City
Family name
Place of birth
State/Province/Region
Given names
(include patronymic name)
Country
Any other names
(eg. maiden or tribal name)
Citizenship(s) and year granted
Sex
M/F
Date of birth
Day
Month
Year
Chinese commercial codes
(If not applicable, write ‘N/A’)
Country of current residence
Migrating with you?
(If not living, write ‘DECEASED’)
No
If more than 6 children, give details at Part T – Additional information
80 (Design date 10/15) - Page 12
© COMMONWEALTH OF AUSTRALIA, 2015
Yes
44 Do you know details of your parents?
Parents include biological parents, adopted parents, step parents, legal guardians and deceased parents.
No
Yes
Give details
(If not living, write ‘DECEASED’ in ‘Country of current residence’ column)
Parent 1
Relationship to you
Town/City
Family name
Place of birth
State/Province/Region
Given names
(include patronymic name)
Any other names
(eg. maiden or tribal name)
Sex
M/F
Date of birth
Day
Year
Chinese commercial codes
(If not applicable, write ‘N/A’)
Country of current residence
Migrating with you?
(If not living, write ‘DECEASED’)
Citizenship(s) and year granted
Country
Month
No
Yes
Parent 2
Relationship to you
Town/City
Family name
Place of birth
State/Province/Region
Given names
(include patronymic name)
Any other names
(eg. maiden or tribal name)
Sex
M/F
Date of birth
Day
Year
Chinese commercial codes
(If not applicable, write ‘N/A’)
Country of current residence
Migrating with you?
(If not living, write ‘DECEASED’)
Citizenship(s) and year granted
Country
Month
No
Yes
Parent 3
Relationship to you
Town/City
Family name
Place of birth
State/Province/Region
Given names
(include patronymic name)
Any other names
(eg. maiden or tribal name)
Sex
M/F
Date of birth
Day
Year
Chinese commercial codes
(If not applicable, write ‘N/A’)
Country of current residence
Migrating with you?
(If not living, write ‘DECEASED’)
Citizenship(s) and year granted
Country
Month
No
Yes
Parent 4
Relationship to you
Town/City
Family name
Place of birth
State/Province/Region
Given names
(include patronymic name)
Country
Any other names
(eg. maiden or tribal name)
Citizenship(s) and year granted
Sex
M/F
Date of birth
Day
Month
Year
Chinese commercial codes
(If not applicable, write ‘N/A’)
Country of current residence
Migrating with you?
(If not living, write ‘DECEASED’)
No
Yes
If more than 4 parents, give details at Part T – Additional information
© COMMONWEALTH OF AUSTRALIA, 2015
80 (Design date 10/15) - Page 13
45 Do you have siblings?
Siblings include full, half and adopted brothers and sisters.
No
Yes
Give details
(If not living, write ‘DECEASED’ in ‘Country of current residence’ column)
Sibling 1
Relationship to you
Town/City
Family name
Place of birth
State/Province/Region
Given names
(include patronymic name)
Any other names
(eg. maiden or tribal name)
Sex
M/F
Date of birth
Day
Year
Chinese commercial codes
(If not applicable, write ‘N/A’)
Country of current residence
Citizenship(s) and year granted
Country
Month
Migrating with you?
No
Yes
Sibling 2
Relationship to you
Town/City
Family name
Place of birth
State/Province/Region
Given names
(include patronymic name)
Any other names
(eg. maiden or tribal name)
Sex
M/F
Date of birth
Day
Year
Chinese commercial codes
(If not applicable, write ‘N/A’)
Country of current residence
Citizenship(s) and year granted
Country
Month
Migrating with you?
No
Yes
Sibling 3
Relationship to you
Town/City
Family name
Place of birth
State/Province/Region
Given names
(include patronymic name)
Any other names
(eg. maiden or tribal name)
Sex
M/F
Date of birth
Day
Year
Chinese commercial codes
(If not applicable, write ‘N/A’)
Country of current residence
Citizenship(s) and year granted
Country
Month
Migrating with you?
No
Yes
Sibling 4
Relationship to you
Town/City
Family name
Place of birth
State/Province/Region
Given names
(include patronymic name)
Country
Any other names
(eg. maiden or tribal name)
Citizenship(s) and year granted
Sex
M/F
Date of birth
Day
Month
Year
Chinese commercial codes
(If not applicable, write ‘N/A’)
Country of current residence
Migrating with you?
No
80 (Design date 10/15) - Page 14
© COMMONWEALTH OF AUSTRALIA, 2015
Yes
Sibling 5
Relationship to you
Town/City
Family name
Place of birth
State/Province/Region
Given names
(include patronymic name)
Any other names
(eg. maiden or tribal name)
Sex
M/F
Date of birth
Day
Year
Chinese commercial codes
(If not applicable, write ‘N/A’)
Country of current residence
Citizenship(s) and year granted
Country
Month
Migrating with you?
No
Yes
If more than 5 siblings, give details at Part T – Additional information
46 Other travelling family members
Are there any other family members included in the visa application?
Family members include nieces, nephews, cousins, in-laws, grandparents etc. who are travelling with you
No
Yes
Give details
Family member 1
Relationship to you
Town/City
Family name
Place of birth
State/Province/Region
Given names
(include patronymic name)
Any other names
(eg. maiden or tribal name)
Sex
M/F
Date of birth
Day
Year
Country of current residence
Citizenship(s) and year granted
Country
Month
Chinese commercial codes
(If not applicable, write ‘N/A’)
Family member 2
Relationship to you
Town/City
Family name
Place of birth
State/Province/Region
Given names
(include patronymic name)
Country
Any other names
(eg. maiden or tribal name)
Citizenship(s) and year granted
Sex
M/F
Date of birth
Day
Month
Year
Chinese commercial codes
(If not applicable, write ‘N/A’)
Country of current residence
If more than 2 other family members, give details at Part T – Additional information
© COMMONWEALTH OF AUSTRALIA, 2015
80 (Design date 10/15) - Page 15
47 Do you have any personal contacts in Australia?
48 Do you have any other personal contacts in Australia?
Personal contacts include visa sponsors, any relatives, friends, family
members and acquaintances in Australia.
No
Go to Part R
Provide as much information about one of your personal
contacts as possible
Family name
No
Go to Part R
Yes
Give details
Family name
Yes
Given names
Given names
Female
Sex
Male
Relationship to you (eg. partner, sister, aunt, friend)
Female
Sex
Male
Relationship to you (eg. partner, sister, aunt, friend)
Day
Month
Year
Date of birth
Day
Month
Town/City of birth
Year
Date of birth
State/Province/Region
Town/City of birth
State/Province/Region
Country
Nationality
Country
Your personal contact’s current residential address
Note: A post office box is not acceptable.
Address (including building/unit/house number and street name)
Nationality
Your personal contact’s current residential address
Note: A post office box is not acceptable.
Address (including building/unit/house number and street name)
Suburb and town/city
Suburb and town/city
State or territory
Postcode
Telephone numbers
State or territory
Telephone numbers
Office hours
Mobile/cell
(Area code
Postcode
Office hours
)
Mobile/cell
)
Email address
Give details of all other contacts at Part T – Additional information
Email address
80 (Design date 10/15) - Page 16
(Area code
© COMMONWEALTH OF AUSTRALIA, 2015
Part R – Sponsoring employer details
WARNING: Giving false or misleading information is a serious offence.
49 Are you being sponsored by, or associated with, a business or
organisation in Australia?
No
Part S – Declaration
53 I declare that:
Go to Part S
• the information I have supplied in or with this form is complete,
correct and up-to-date in every detail.
• I have read and understand the information supplied to me.
• I have read the information contained in form 1442i Privacy notice.
• I understand the department may collect, use and disclose my
personal information (including biometric information and other
sensitive information) as outlined in form 1442i Privacy notice.
Yes
Give details
Organisation/Business name
Organisation/Business description
Organisation/Business commercial address (including building number
and street name)
Signature of
applicant
Day
Month
Year
Date
We strongly advise that you keep a copy of your application
and all attachments for your records.
Suburb and town/city
State or territory
Postcode
Name of contact person in business/organisation
50 Does the employer/business have any other associated addresses?
No
Yes
Give details
Type of address (eg. head office, factory, retail store)
Address (including building number and street name)
Suburb and town/city
State or territory
Postcode
51 Does the employer/business have an email address?
No
Yes
Give details
52 Does the employer/business have telephone numbers?
No
Yes
List all contact telephone numbers (including area code)
© COMMONWEALTH OF AUSTRALIA, 2015
80 (Design date 10/15) - Page 17
Part T – Additional information
54
Question
number
Additional information
If you do not have enough space to give all the necessary information, attach a separate statement to this form with further details
80 (Design date 10/15) - Page 18
© COMMONWEALTH OF AUSTRALIA, 2015