Form
Personal particulars for assessment
including character assessment
80
Department of Home Affairs
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 open this form using Adobe Acrobat Reader.
Either type (in English) in the fields provided or print this form
and complete it (in English) using a pen and 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 Home Affairs (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.
Part A – Applicant details
1
Important information about privacy
The Privacy Act 1988 contains 13 Australian Privacy Principles
which regulate the way that the Department collects and handles
personal information. Information about how the Department
collects, uses and discloses personal information for its key
functions can be found in form 1442i Privacy notice. More
information about the Department’s general information handling
practices (including form 1442i) can be found in the Department’s
Privacy policy at https://www.homeaffairs.gov.au/access-andaccountability/our-commitments/privacy
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
Shariati Najafabadi
All given names
Parisaalsadat
Sex
Male
Day
Date of birth
Indeterminate /
Intersex / Unspecified
Female ✔
Month
31-May-1989
Year
Day, month and year
MUST be provided
Suburb of birth
Town/City of birth ISFAHAN
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
IRAN
Chinese Commercial Code Number (in full)
Are you of Russian descent?
No ✔
Yes
© COMMONWEALTH OF AUSTRALIA, 2021
In English, provide your patronymic name
80 (Design date 03/21) - 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
B52581774
Family name
Country of passport/travel document
IRAN
Given names
Day
Date of issue
Month
Year
13-Feb-2020
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
Give original issue date
Day
Month
Date of expiry
12-Feb-2025
Do you currently have citizenship from any country?
Nationality
IRAN
No, I am stateless
Place of issue/issuing authority
Give details
Month
Year
Year
IMMIGRATION AND PASSPORT POLICE
Yes ✔
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)?
SAME AS QUESTION 1
Given names
BIRTH
Day
Date you gained this citizenship
7
Month
Year
SAME AS QUESTION 1
31-May-1989
Do you hold or have you held citizenship from any other country
(including dual citizenships and all previous citizenships)?
No ✔
Yes
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
8
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 03/21) - Page 2
© COMMONWEALTH OF AUSTRALIA, 2021
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
I33039464
Country of passport/travel document
Country of passport/travel document
IRAN
Day
Month
Day
Year
Month
Date of issue
Date of issue
29-Jan-2015
Date of expiry
Date of expiry
29-Jan-2020
Nationality
Nationality
IRAN
Place of issue/issuing authority
Place of issue/issuing authority
Year
IMMIGRATION AND PASSPORT POLICE
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
SAME AS QUESTION 1
Given names
Given names
SAME AS QUESTION 1
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
Country of issue
Identification number
shown (if applicable)
BIRTH CERTIFIC IRAN
1080020446
NATIONAL IDEN IRAN
1080020446
© COMMONWEALTH OF AUSTRALIA, 2021
80 (Design date 03/21) - 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 or legal practitioner email addresses.
No
Yes ✔
No
Provide all telephone numbers
Country code
Yes ✔
Provide all of your email addresses
Primary
PARISAN.SHARIATI@YAHOO.COM
Other
Area code
Number
Work
(
) (
)
Home
( 98
) ( 31
)
Mobile/cell
00989133335806
42654409
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)
CURRENT
Jun-2013
Country
Year
May-2012 Jun-2013
NO.50,SHAHID SANEEI ST, SHOHADA ST, NAJAFABAD, ESFAHAN,
8518748714
IRAN
NO.12, OMID ALLEY, MOLAVI ST, NAJAFABAD, ESFAHAN,
8514849145
IRAN
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
30-Sep-2021
80 (Design date 03/21) - Page 4
Date to
Year
Day
Month
07/10/2021
Reason for visit
Country
Year
HOLIDAY OR LEISURE
© COMMONWEALTH OF AUSTRALIA, 2021
TURKEY
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
May-2021
Date to
Month
Year
CURRENT
May-2017 Feb-2020
Jun-2016
May-2017
Sep-2013
Sep-2015
Sep-2007
Jul-2011
Your occupation and duties
OR
If unemployed/retired/never worked,
provide details of how you occupied your time
and financially supported yourself
Type of business
(eg. government
department, bakery)
Name of business/company
(no abbreviations)
Full address of business/company
(Building number, street name, suburb,
town/city, state/province)
(no Post Office box)
Country
SHAHDAVARAN ASAL
NAJAFABAD
PACKAGING AND
SELLING HONEY
HUMAN RESOURCE MANAGER
RECRUITING,
HIRING,DEPLOYING AND
MANAGING OF ORGANIZATION'S
EMPLOYEE
RAZI ST, NAJAFABAD
INDUSTRIAL ZONE NO.2,
NAJAFABAD, ESFAHAN
IRAN
ATI NIROO SEPAHAN
ENGINEERING
HUMAN RESOURCE MANAGER
COORDINATING ALL
ADMINISTRATIVE ACTIVITYS
RELATED TO THE
ORGANIZATION'S PERSONEL
NO 76, MODAFEEINE HARAM
SQUARE, NAJAFABAD ,ESFAHAN
IRAN
GHODS GROUP
MANUFACTURING
TRUCK BODY
PARTS
HR SPECIALIST
NO 4 STREET, INDUSTRIAL ZONE
SOURCING AND REACHING OUT
NO.1, NAJAFABAD, ISFAHAN
TO QUALIFIED FOR CURRENT
OPEN ROLES AND ANY ACTIVITY
RELATED TO HR
IRAN
UNEMPLOYMENT
-
STUDYING MASTER DEGREE AT
UNIVIERSITY
16th Azar St., Enghelab Sq., Tehran
IRAN
STUDYING BACHELOR AT
UNIVIERSITY
Varzesh Sq. Dehkadeh-ye-Olympic,
Tehran
IRAN
UNEMPLOYMENT
© COMMONWEALTH OF AUSTRALIA, 2021
80 (Design date 03/21) - 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
Sep-2013
Date to
Month
Year
09/2015
Full name of institution
(no abbreviations)
University of Tehran
Full name of course or description of research/
Thesis and supervisor details (no abbreviations)
Course status
Campus/address of institution
Completed ✔ 16th Azar St., Enghelab Sq., Tehran
Humsn resource management
Country
Iran
Withdrew
Currently enrolled
Sep-2007
Jul-2011
Allameh Tabataba'i University
Completed ✔ Varzesh Sq. Dehkadeh-ye-Olympic, Tehran Iran
Tourism management
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 03/21) - Page 6
© COMMONWEALTH OF AUSTRALIA, 2021
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, 2021
80 (Design date 03/21) - 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 03/21) - Page 8
© COMMONWEALTH OF AUSTRALIA, 2021
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
Place of visa issue
© COMMONWEALTH OF AUSTRALIA, 2021
Arrival date
Day
Month
Departure date
Year
Day
Month
Year
80 (Design date 03/21) - Page 9
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
• been convicted of an offence in any country
(including any conviction which is now
removed from official records)?
No
Yes
• been charged or convicted of family or
domestic violence offences or similar related
offences?
No ✔
Yes
• been the subject of a domestic or family
violence order, or any other order, of a tribunal
or court or other similar authority, for the
personal protection of another person?
No ✔
Yes
• been the subject of an arrest warrant or
Interpol notice?
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
• 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 removed, deported or excluded from any
country (including Australia)?
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
80 (Design date 03/21) - Page 10
If you answered ‘Yes’ to any question at Question 36, give details,
including the date of the charge, the outcome and any penalty imposed.
Also attach court documents (for example sentencing remarks or court
transcripts).
Where relevant, provide a copy of all declared orders (for example, any
domestic or family violence orders, child protection orders, or orders that
prohibit the applicant from having contact with another person for their
personal protection). You are only requested to declare an order where
the applicant is the respondent or subject of the order. You are not asked
to declare an order where the applicant is the person requiring personal
protection.
© COMMONWEALTH OF AUSTRALIA, 2021
Part L – Military service
37 Have you undertaken any military service?
Military service includes:
• compulsory
• conscription
• military training
• voluntary
• professional.
No ✔
Give reasons Women does not have Military service in Iran
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
and Unit ID number
any country?
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
39 Have you ever been refused a visa to any country?
Yes
Country of
deployment
40 Have you ever been excluded, asked to leave, deported or removed from
officer or an agent of an intelligence or security agency?
No
Duties
Part O – Deportations
38 Are you currently, or have you been employed as an intelligence
Yes
Rank
country?
✔
Give dates of refusal, countries and circumstances of
refusal
No
Yes
© COMMONWEALTH OF AUSTRALIA, 2021
✔
Give dates of refusal, countries and circumstances of
refusal
80 (Design date 03/21) - Page 11
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
Husband
Given names
(include patronymic name)
Family name
Rahimzadeh Najafabadi
Town/City
Najafabad
Hossein
Place of birth
State/Province/Region
Isfahan
Any other names
(eg. maiden or tribal name)
M
Date of birth
Day
Month
Year
Chinese commercial codes
(If not applicable, write ‘N/A’)
N/A
04-Nov-1983
Country of current residence
Migrating with you?
(If not living, write ‘DECEASED’)
Citizenship(s) and year granted
Country
Iran
Sex
M/F/X
Iranian, 1983
No
Iran
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/X
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/X
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
80 (Design date 03/21) - Page 12
© COMMONWEALTH OF AUSTRALIA, 2021
Yes
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/X
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/X
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/X
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/X
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 6 children, give details at Part T – Additional information
© COMMONWEALTH OF AUSTRALIA, 2021
80 (Design date 03/21) - Page 13
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
Father
Given names
(include patronymic name)
Family name
Shariati Najafabadi
Town/City
Najafabad
Sayed Rasoul
Place of birth
State/Province/Region
Isfahan
Any other names
(eg. maiden or tribal name)
M
Date of birth
Day
Month
Year
18-Jun-1963
Chinese commercial codes
(If not applicable, write ‘N/A’)
N/A
Country of current residence
Migrating with you?
(If not living, write ‘DECEASED’)
Citizenship(s) and year granted
Country
Iran
Sex
M/F/X
Iranian, 1963
No ✔
Iran
Yes
Parent 2
Relationship to you
Mother
Given names
(include patronymic name)
Family name
Ahmadian Najafabadi
Town/City
Najafabad
Azam
Place of birth
State/Province/Region
Najafabad
Any other names
(eg. maiden or tribal name)
Sex
M/F/X
F
Month
Year
05-Nov-1967
Chinese commercial codes
(If not applicable, write ‘N/A’)
N/A
Country of current residence
Migrating with you?
(If not living, write ‘DECEASED’)
Citizenship(s) and year granted
Country
Najafabad
Date of birth
Day
Iranian, 1967
No ✔
Iran
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/X
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/X
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 4 parents, give details at Part T – Additional information
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© COMMONWEALTH OF AUSTRALIA, 2021
Yes
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/X
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/X
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/X
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/X
Date of birth
Day
Month
Year
Chinese commercial codes
(If not applicable, write ‘N/A’)
Country of current residence
Migrating with you?
No
© COMMONWEALTH OF AUSTRALIA, 2021
Yes
80 (Design date 03/21) - Page 15
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/X
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/X
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
If more than 2 other family members, give details at Part T – Additional information
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Sex
M/F/X
Date of birth
Day
Month
Year
Chinese commercial codes
(If not applicable, write ‘N/A’)
Country of current residence
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
No
Go to Part R
Yes
Give details
Family name
Yes
Provide as much information about one of your personal
contacts as possible
Family name
Given names
Given names
Sex
Male
Indeterminate /
Intersex / Unspecified
Female
Relationship to you (eg. partner, sister, aunt, friend)
Sex
Male
Indeterminate /
Intersex / Unspecified
Female
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
(Area code
)
Mobile/cell
)
Email address
Give details of all other contacts at Part T – Additional information
Email address
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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)
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© COMMONWEALTH OF AUSTRALIA, 2021
Part T – Additional information
54
Question
number
Additional information
19
02/2020 TO 05/2021 I took some days off. financially supported by my savings and my husband
19
09/2015 TO 06/2016 I took some days off, financially supported by my savings and my husband
19
07/2011 to 09/2013 I took some days off, financially supported by my family
19
05/1989 to 09/2007 birth, school and high school, financially supported by my family
If you do not have enough space to give all the necessary information, attach a separate statement to this form with further details
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80 (Design date 03/21) - Page 19