20
80 (Design date 11/13) - Page 1 © COMMONWEALTH OF AUSTRALIA, 2013 Personal particulars for assessment including character assessment Form 80 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 for visas for Australia who are 16 years of age or over, as requested by the office processing the application. 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. About the information you give The department has authority under the Migration Act 1958 and the Australian Citizenship Act 2007 and other legislation it administers, to collect personal information to carry out its functions, including administration of applications for visas for entry and/or stay in Australia or for citizenship. The information provided will be used for assessing your eligibility for a visa to travel to, enter and remain in Australia and for other purposes relating to the administration of the Migration Act, for example, to assist migrants with settling in Australia or for ensuring compliance with the Migration Act. The information provided might also be disclosed to agencies who are authorised to receive information relating to adoption, border control, business skills, citizenship, education, health assessment, health insurance, health services, law enforcement, payment of pensions and benefits, taxation, superannuation, review of decisions and registration of migration agents. The information form 993i Safeguarding your personal information, available from offices of the department, gives details of agencies to which your information might be disclosed. student refugee/ humanitarian entrant visitor migrant temporary resident OR I am applying in Australia for: I am applying for a visa to travel to Australia as a: a further temporary stay or visit protection permanent residence Sex Male Female Family name Nationality Passport/travel document number All given names DAY MONTH YEAR Date of birth 3 Tick where applicable Please use a pen, and write neatly in English using BLOCK LETTERS. Place of birth Suburb and Town/City 1 Write your name and birth details as shown on your current passport, birth certificate, family book or travel document Passport Other Type of document Part A – Your details Note: If your passport/travel document only shows one name, write that name in the Family name box. Country of passport/travel document Place of issue/issuing authority Date of issue Date of expiry DAY MONTH YEAR Day, month and year MUST be provided State/Province/ Region Country

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80 (Design date 11/13) - Page 1© COMMONWEALTH OF AUSTRALIA, 2013

Personal particulars for assessment including character assessment

Form

80

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 for visas for Australia who are 16 years of age or over, as requested by the office processing the application.

Integrity of applicationThe 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.

About the information you giveThe department has authority under the Migration Act 1958 and the Australian Citizenship Act 2007 and other legislation it administers, to collect personal information to carry out its functions, including administration of applications for visas for entry and/or stay in Australia or for citizenship. The information provided will be used for assessing your eligibility for a visa to travel to, enter and remain in Australia and for other purposes relating to the administration of the Migration Act, for example, to assist migrants with settling in Australia or for ensuring compliance with the Migration Act.

The information provided might also be disclosed to agencies who are authorised to receive information relating to adoption, border control, business skills, citizenship, education, health assessment, health insurance, health services, law enforcement, payment of pensions and benefits, taxation, superannuation, review of decisions and registration of migration agents.

The information form 993i Safeguarding your personal information, available from offices of the department, gives details of agencies to which your information might be disclosed.

student

refugee/ humanitarian entrant

visitor

migrant

temporary resident

OR

I am applying in Australia for:

I am applying for a visa to travel to Australia as a:

a further temporary stay or visit

protection

permanent residence

Sex Male Female

Family name

Nationality

Passport/travel document number

All given names

DAY MONTH YEAR

Date of birth

3Tick where applicable

Please use a pen, and write neatly in English using BLOCK LETTERS.

Place of birthSuburb and Town/City

1 Write your name and birth details as shown on your current passport, birth certificate, family book or travel document

Passport

Other Type of document

Part A – Your details

Note: If your passport/travel document only shows one name, write that name in the Family name box.

Country of passport/travel document

Place of issue/issuing authority

Date of issue

Date of expiry

DAY MONTH YEAR

Day, month and year MUST be provided

State/Province/Region

Country

80 (Design date 11/13) - Page 2 © COMMONWEALTH OF AUSTRALIA, 2013

3 Does the passport/travel document at Question 1 show your full name?

No

No

Yes

Yes

What is your full name?

Write the number of the document you used to enter Australia

Family name

Given names

4

5

6

9

10

8

Do you ever use a Chinese Commercial Code Number for your names shown in the passport/travel document at Question 1

Are you of Arabic descent?

Have you ever had a different date of birth?

Are you a citizen of the country of passport/travel document at Question 1?

Have you ever been known by other names or spellings of your name?

No

No

No

No

No

Yes

Yes

Yes

Yes

Yes

Did you use the passport/travel document at Question 1 to enter Australia?

Chinese Commercial Code Number (in full)

In English, write the full name of your father’s father (ie. your paternal grandfather)

Give details in English

Different date of birth

How did you gain this citizenship (eg. birth, descent, naturalisation)?

Date you gained this citizenship

Type of name

Type of name

Family name

Family name

Given names

Given names

2.

1.

DAY MONTH YEAR

DAY MONTH YEAR

If more than 2, give details at Part K – Additional details

Examples of the types of other names:

• 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

2 Relationship status

Married

De facto

Engaged

Divorced

Separated

Widowed

Never married or been in a de facto

relationship

Date of marriage

Date of intended marriage

Date relationship began

DAY MONTH YEAR7 Are you of Russian descent?

No

Yes In English, provide your patronymic name

80 (Design date 11/13) - Page 3© COMMONWEALTH OF AUSTRALIA, 2013

11

12

14

Do you currently have, or have you ever had, other passports/travel documents not already shown at Question 1?

Are you currently, or have you ever been, a citizen of any other country not already shown at Question 1 or Question 11?

Do you currently have permanent residence rights in any country not already shown at Question 1, Question 11 or Question 12?

No

No

No

Yes

Yes

Yes

Give details as they appear on the other passports/travel documents (If more than one, give details at Part K – Additional details)

Give details

Give details

Family name

Nationality

Passport/travel document number

All given names

Note: If the passport/travel document only shows one name, write that name in the Family name box.

Country of passport/travel document

Place of issue/issuing authority

Are you, or have you ever been, a citizen of the country of passport/travel document shown above?

Date of issue

From

From

Date of expiry

To (If you still have the citizenship, write ‘Current’)

To (If you still have the citizenship, write ‘Current’)

DAY MONTH YEAR

DAY MONTH YEAR

DAY MONTH YEAR

No

Yes How did you gain this citizenship (eg. birth, descent, naturalisation)?

How did you gain this citizenship (eg. birth, descent, naturalisation)?

When did you have this citizenship?

When did you have this citizenship?

Country

Country

Country

1.

1.

2.

13 Have you ever renounced any citizenship you have previously held?

No

Yes Give details

Country

Reason

Date of renouncementDAY MONTH YEAR

From

To (If you still have the citizenship, write ‘Current’)

DAY MONTH YEAR

How did you gain this citizenship (eg. birth, descent, naturalisation)?

When did you have this citizenship?

If more than 2, give details at Part K – Additional details

Country2.

15 Have you ever been refused citizenship of any country?

No

Yes Give details

Reason for refusal

Reason for refusal

Date

Date

DAY MONTH YEAR

DAY MONTH YEAR

Country

Country

1.

2.

If more than 2, give details at Part K – Additional details

80 (Design date 11/13) - Page 4 © COMMONWEALTH OF AUSTRALIA, 2013

17 Your current residential address (this is the place where you currently live) Note: A post office box or mailbox address is not acceptable as a residential address.

Unit/Apartment number

Postal code

Address (including street number and name)

16

Country of issueType of identification document Name shown on documentIdentification number shown (if applicable)

Do you currently have, or have you ever had, any national identity documents or numbers (including birth registration numbers, social security cards etc)?

No

Yes Give details

18 Do you have an e-mail address? Note: Do not provide the e-mail address of a migration agent.

No

Yes Please provide all of your e-mail addresses

19 Your current contact numbers (include country code if outside Australia)

( ) ( )

( ) ( )

COUNTRY CODE AREA CODE

Work

Home

Mobile/cell

( ) ( )

( ) ( )

( ) ( )Fax

Other contact numbers you have

NUMBER

Suburb and Town/City

State/Province/Region

Country20 Address in Australia where you can be contacted or will be staying

Note: A post office box or mailbox address is not acceptable.

POSTCODE

21 Contact telephone numbers in Australia (if known)

( )

( )

AREA CODE

Work

Home

Mobile/cell

( )

( )

Other contact numbers

NUMBER

80 (Design date 11/13) - Page 5© COMMONWEALTH OF AUSTRALIA, 2013

22 Do you have personal contacts in Australia (including business contacts/sponsor)? Note: Do not provide the contact details of a migration agent.

No

Yes Give details

Given names

Family name

Sex Male Female

Date of birth

Relationship to you (eg. partner, sister, aunt, friend, business contact/sponsor)

( )

AREA CODE NUMBERTelephone number

1.

If more than 2, give details at Part K – Additional details

DAY MONTH YEAR

Place of birth

Suburb and Town/City

Nationality

State/Province/ Region

Country

Your personal contact’s current residential address Note: A post office box or mailbox address is not acceptable as a residential address.

Unit/Apartment number

Postal code

Address (including street number and name)

State/Province/Region

Country

Given names

Family name

Sex Male Female

Date of birth

Relationship to you (eg. partner, sister, aunt, friend, business contact/sponsor)

( )

AREA CODE NUMBERTelephone number

2.

DAY MONTH YEAR

Place of birth

Nationality

State/Province/ Region

Country

Your personal contact’s current residential address Note: A post office box or mailbox address is not acceptable as a residential address.

Unit/Apartment number

Postal code

Address (including street number and name)

State/Province/Region

Country

Suburb and Town/City

Suburb and Town/City

Suburb and Town/City

E-mail address

E-mail address

80 (Design date 11/13) - Page 6 © COMMONWEALTH OF AUSTRALIA, 2013

27 Your partner’s place of birth

Family name

All given names

24 Your partner’s full name

Part B – Your partner’s details

25

26

Sex Male Female

Date of birth

Date of death (if deceased)

DAY MONTH YEAR

28

23

Is your partner currently, or have they ever been, a citizen of any country?

Do you currently have a partner?Note: If you are widowed, you must answer ‘Yes’ and give details for your deceased partner.

No

No

Yes

Yes

Give details

From

From

To (If they still have the citizenship, write ‘Current’)

To (If they still have the citizenship, write ‘Current’)

DAY MONTH YEAR

DAY MONTH YEAR

When did your partner have this citizenship?

When did your partner have this citizenship?

If more than 2, give details at Part K – Additional details

Country

Country

1.

2.

29

33

Does your partner ever use a Chinese Commercial Code Number for names shown at Question 24?

Country where your partner lives now If in Australia, write the full address, if deceased, write ‘DECEASED’

No

Yes Chinese Commercial Code Number (in full)

Go to Part C

State/Province/Region

Country

32 Is your partner currently, or have they ever been, known by other names or spellings of their name?

No

Yes Give details in English

Type of name

Type of name

Family name

Family name

Given names

Given names

2.

1.

If more than 2, give details at Part K – Additional details

30 Is your partner of Arabic descent?

No

Yes In English, write the full name of your partner’s father’s father (ie. paternal grandfather)

Examples of the types of other names:

• 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

In English, provide your partner’s patronymic name

31 Is your partner of Russian descent?

No

Yes

Day, month and year MUST be provided

POSTCODE

Suburb and Town/City

80 (Design date 11/13) - Page 7© COMMONWEALTH OF AUSTRALIA, 2013

34

Country of issueType of identification document Name shown on documentIdentification number shown (if applicable)

Does your partner currently have, or have they ever had, any national identity documents or numbers (including birth registration numbers, social security cards etc)?

No

Yes Give details

Details of proposed final departure from Australia

38

39

Are you applying for a temporary visa?

What is the main reason for going to Australia? Include details of any dates that are of special significance to your time in Australia.

No

Yes

Part C – Travel to Australia

Departure date

Flight number or vessel details (if known)

DAY MONTH YEAR

City of departure

Details of proposed arrival in Australia37

Arrival date

Date of birth

Date of birth

Flight number or vessel details (if known)

Country of birth

Country of birth

Nationality

Nationality

DAY MONTH YEAR

DAY MONTH YEAR

DAY MONTH YEAR

City of arrival

Go to Part E

35 Are you planning to travel to Australia with any other person(s) OR if you are in Australia did you travel with any other person(s)?

No

Yes Give details

Family name

Family name

Relationship to you (eg. partner, sister, friend, business contact)

Relationship to you (eg. partner, sister, friend, business contact)

Given names

Given names

1.

2.

If more than 2, give details at Part K – Additional details

Go to Part D

36 Are you currently in Australia?

No

Yes

80 (Design date 11/13) - Page 8 © COMMONWEALTH OF AUSTRALIA, 2013

Go to Part E

40 Do you currently hold an Australian visa?

No

Yes

Part D – Current visa details

Details of your arrival in Australia

Final date you must leave Australia on this visa

42

43

Arrival date

Date of issue

DAY MONTH YEAR

DAY MONTH YEAR

DAY MONTH YEAR

City of arrival

NOTE: Only complete this Part if you are currently in Australia

41 Visa details

Type of visa

Place of issue

44 Have you travelled to Australia before?

Give details in chronological order (If insufficient space, give details at Part K – Additional details)

Give details in chronological order (If insufficient space, give details at Part K – Additional details)

No

No

Yes

Yes

Part E – Other information

DAY MONTH YEAR DAY MONTH YEAR

Date from Date toYour names shown on visa

Place where visa was issued

Type of visa (eg. visitor, student, business) Reason for visit

45 Have you travelled to any country other than Australia, including any visits back to your country of citizenship during the past 10 years (including short stays)? 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 (both month and year are required).

Country or countries Reason for visitDAY MONTH YEAR DAY MONTH YEAR

Date from Date to

80 (Design date 11/13) - Page 9© COMMONWEALTH OF AUSTRALIA, 2013

Name and address of employer/business. Do not use abbreviations.

Type of business/ other activities

Your position/title/duties/how you spent your time if unemployed

Date from Date toMONTH YEAR MONTH YEAR

46 List, in chronological order, the addresses of the places where you have lived during the last 10 years (including Australia). You must account for every month/year. If you are unable to provide an address for any period of time please provide an explanation. (If insufficient space, give details at Part K – Additional details)

Note: If you are applying for a refugee/humanitarian visa you must provide all addresses for the last 30 years (both month and year are required with no gaps).

Date from Date toCountry Full address (number, street name, suburb, state/province, region)

MONTH YEAR MONTH YEAR

47 Give details of all employment including periods of unemployment.

Note: If you are unable to provide details for a period, please provide an explanation. (If insufficient space, give details at Part K – Additional details)

For current or previous periods of unemployment please advise how you occupied your time and how you supported yourself. Month and year are both required. If retired, please provide activities. Time gaps are unacceptable.

80 (Design date 11/13) - Page 10 © COMMONWEALTH OF AUSTRALIA, 2013

48

49

Have you had any military service?

List all education and qualifications undertaken, including courses completed, withdrawn or continuing. (If insufficient space, give details at Part K – Additional details)

Give details in chronological order.

Give details in chronological order (If insufficient space, give details at Part K – Additional details)

No

Yes

RankFull name of Unit/ Battalion/BrigadeCountry of service Duties

Country of deployment

DAY MONTH YEAR DAY MONTH YEAR

Date from Date to

Name and address of institution. Do not use abbreviations.

Country where course undertaken

Course of study. Do not use abbreviations. Course statusDate from Date to

MONTH YEAR MONTH YEAR

Completed course

Completed course

Completed course

Completed course

Withdrew

Withdrew

Withdrew

Withdrew

Currently enrolled

Currently enrolled

Currently enrolled

Currently enrolled

Have you undertaken an academic thesis, dissertation or publication (including completed, withdrawn or continuing theses, dissertations or publications)?

Give details

Full name of your supervisor

No

Yes

Family name

50

Given names

80 (Design date 11/13) - Page 11© COMMONWEALTH OF AUSTRALIA, 2013

51

Note: You must give details for any person (living or deceased) who is or was your parent or with whom you have had a parent-like relationship. This should include, but is not limited to, natural parents, adoptive parents, surrogate parents, step-parents, foster parents, and/or guardians.

Provide details of one parent at Question 51 and the other parent at Question 52. If more than 2, give details at Part K – Additional details.

Relationship to you (eg. natural parent, step-parent etc)

Country where this parent lives now If in Australia, write the full address, if not living, write ‘DECEASED’

Part F – About your parents

This parent’s place of birth

Sex Male Female

Date of birthDAY MONTH YEAR

Is this parent currently, or have they ever been, a citizen of any country?

Yes Give details

From

From

To (If they still have the citizenship, write ‘Current’)

To (If they still have the citizenship, write ‘Current’)

DAY MONTH YEAR

DAY MONTH YEAR

No

When did this parent have this citizenship?

When did this parent have this citizenship?

Country

Country

1.

a.

l.

i.

k.

b.

c.

d.

e.

f.

g.

2.

Is this parent of Arabic descent?

In English, write the full name of this parent’s father

No

No

YesParent

This parent’s full nameFamily name

All given names including, if applicable, patronymic name (in English), clan and sub-clan names, and middle names

Is this parent currently, or have they ever been, known by other names or spellings of their name?

No Yes Give details in English

Type of name

Type of name

Family name

Family name

Given names

Given names

h. Does this parent ever use a Chinese Commercial Code Number?

Yes Chinese Commercial Code Number (in full)

2.

1.

Date of death (if deceased)

Examples of the types of other names:

• 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

j.

In English, provide this parent’s patronymic name

Is this parent of Russian descent?

No

Yes

POSTCODE

Suburb and Town/City

State/Province/Region

Country

80 (Design date 11/13) - Page 12 © COMMONWEALTH OF AUSTRALIA, 2013

52Relationship to you (eg. natural parent, step-parent etc)

Country where this parent lives now If in Australia, write the full address, if not living, write ‘DECEASED’

This parent’s place of birth

Sex Male Female

Date of birthDAY MONTH YEAR

Is this parent currently, or have they ever been, a citizen of any country?

Yes Give details

From

From

To (If they still have the citizenship, write ‘Current’)

To (If they still have the citizenship, write ‘Current’)

DAY MONTH YEAR

DAY MONTH YEAR

No

When did this parent have this citizenship?

When did this parent have this citizenship?

Country

Country

1.

a.

l.

i.

k.

b.

c.

d.

e.

f.

g.

2.

Is this parent of Arabic descent?

In English, write the full name of this parent’s father

No

No

Yes

Parent

This parent’s full nameFamily name

All given names including, if applicable, patronymic name (in English), clan and sub-clan names, and middle names

Is this parent currently, or have they ever been, known by other names or spellings of their name?

No Yes Give details in English

Type of name

Type of name

Family name

Family name

Given names

Given names

h. Does this parent ever use a Chinese Commercial Code Number?

Yes Chinese Commercial Code Number (in full)

2.

1.

Date of death (if deceased)

Examples of the types of other names:

• 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

j.

In English, provide this parent’s patronymic name

Is this parent of Russian descent?

No

Yes

POSTCODE

Suburb and Town/City

State/Province/Region

Country

80 (Design date 11/13) - Page 13© COMMONWEALTH OF AUSTRALIA, 2013

53Relationship to you (eg. brother, sister, step-brother, step-sister)

Country where this person lives now If in Australia, write the full address, if not living, write ‘DECEASED’

Part G – About your brothers and sisters

Place of birth

Sex Male Female

Date of birthDAY MONTH YEAR

Is this person currently, or have they ever been, a citizen of any country?

Yes Give details

From

From

To (If they still have the citizenship, write ‘Current’)

To (If they still have the citizenship, write ‘Current’)

DAY MONTH YEAR

DAY MONTH YEAR

No

When did this person have this citizenship?

When did this person have this citizenship?

Country

Country

1.

a.

l.

i.

k.b.

c.

d.

e.

f.

g.

2.

Is this person of Arabic descent?

In English, write the full name of this person’s father’s father (ie. paternal grandfather)

No

Yes

Brother or sister

Family name

All given names including, if applicable, patronymic name (in English), clan and sub-clan names, and middle names

Is this person currently, or have they ever been, known by other names or spellings of their name?

No

Yes Give details in English

Type of name

Type of name

Family name

Family name

Given names

Given names

2.

1.Date of death (if deceased)

Note: You must give details for any person (living or deceased) who is or was your brother or sister. This should include, but is not limited to, natural brothers and sisters, adoptive brothers and sisters, step-brothers and sisters.

Provide details of one brother or sister at Question 53 and the others at Questions 54–56. If more than 4, give details at Part K – Additional details.

No

h. Does this person ever use a Chinese Commercial Code Number?

Yes Chinese Commercial Code Number (in full)

Examples of the types of other names:

• 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

j.

In English, provide their patronymic name

Is this person of Russian descent?

No

Yes

POSTCODE

Suburb and Town/City

State/Province/Region

Country

80 (Design date 11/13) - Page 14 © COMMONWEALTH OF AUSTRALIA, 2013

54Relationship to you (eg. brother, sister, step-brother, step-sister)

Country where this person lives now If in Australia, write the full address, if not living, write ‘DECEASED’

Place of birth

Sex Male Female

Date of birthDAY MONTH YEAR

Is this person currently, or have they ever been, a citizen of any country?

Yes Give details

From

From

To (If they still have the citizenship, write ‘Current’)

To (If they still have the citizenship, write ‘Current’)

DAY MONTH YEAR

DAY MONTH YEAR

No

When did this person have this citizenship?

When did this person have this citizenship?

Country

Country

1.

a.

l.

i.

k.

b.

c.

d.

e.

f.

g.

2.

Is this person of Arabic descent?

In English, write the full name of this person’s father’s father (ie. paternal grandfather)

No

Yes

Brother or sister

Family name

All given names including, if applicable, patronymic name (in English), clan and sub-clan names, and middle names

Is this person currently, or have they ever been, known by other names or spellings of their name?

No

Yes Give details in English

Type of name

Type of name

Family name

Family name

Given names

Given names

2.

1.

Date of death (if deceased)

No

h. Does this person ever use a Chinese Commercial Code Number?

Yes Chinese Commercial Code Number (in full)

Examples of the types of other names:

• 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

j.

In English, provide their patronymic name

Is this person of Russian descent?

No

Yes

POSTCODE

Suburb and Town/City

State/Province/Region

Country

80 (Design date 11/13) - Page 15© COMMONWEALTH OF AUSTRALIA, 2013

55Relationship to you (eg. brother, sister, step-brother, step-sister)

Country where this person lives now If in Australia, write the full address, if not living, write ‘DECEASED’

Place of birth

Sex Male Female

Date of birthDAY MONTH YEAR

Is this person currently, or have they ever been, a citizen of any country?

Yes Give details

From

From

To (If they still have the citizenship, write ‘Current’)

To (If they still have the citizenship, write ‘Current’)

DAY MONTH YEAR

DAY MONTH YEAR

No

When did this person have this citizenship?

When did this person have this citizenship?

Country

Country

1.

a.

l.

i.

k.

b.

c.

d.

e.

f.

g.

2.

Is this person of Arabic descent?

In English, write the full name of this person’s father’s father (ie. paternal grandfather)

No

Yes

Brother or sister

Family name

All given names including, if applicable, patronymic name (in English), clan and sub-clan names, and middle names

Is this person currently, or have they ever been, known by other names or spellings of their name?

No

Yes Give details in English

Type of name

Type of name

Family name

Family name

Given names

Given names

2.

1.

Date of death (if deceased)

No

h. Does this person ever use a Chinese Commercial Code Number?

Yes Chinese Commercial Code Number (in full)

Examples of the types of other names:

• 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

j.

In English, provide their patronymic name

Is this person of Russian descent?

No

Yes

POSTCODE

Suburb and Town/City

State/Province/Region

Country

80 (Design date 11/13) - Page 16 © COMMONWEALTH OF AUSTRALIA, 2013

56Relationship to you (eg. brother, sister, step-brother, step-sister)

Country where this person lives now If in Australia, write the full address, if not living, write ‘DECEASED’

Place of birth

Sex Male Female

Date of birthDAY MONTH YEAR

Is this person currently, or have they ever been, a citizen of any country?

Yes Give details

From

From

To (If they still have the citizenship, write ‘Current’)

To (If they still have the citizenship, write ‘Current’)

DAY MONTH YEAR

DAY MONTH YEAR

No

When did this person have this citizenship?

When did this person have this citizenship?

Country

Country

1.

a.

l.

i.

k.

b.

c.

d.

e.

f.

g.

2.

Is this person of Arabic descent?

In English, write the full name of this person’s father’s father (ie. paternal grandfather)

No

Yes

Brother or sister

Family name

All given names including, if applicable, patronymic name (in English), clan and sub-clan names, and middle names

Is this person currently, or have they ever been, known by other names or spellings of their name?

No

Yes Give details in English

Type of name

Type of name

Family name

Family name

Given names

Given names

2.

1.

Date of death (if deceased)

No

h. Does this person ever use a Chinese Commercial Code Number?

Yes Chinese Commercial Code Number (in full)

Examples of the types of other names:

• 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

j.

In English, provide their patronymic name

Is this person of Russian descent?

No

Yes

POSTCODE

Suburb and Town/City

State/Province/Region

Country

80 (Design date 11/13) - Page 17© COMMONWEALTH OF AUSTRALIA, 2013

57Relationship to you (eg. son, daughter)

Country where this person lives now If in Australia, write the full address, if not living, write ‘DECEASED’

Part H – About your children

Place of birth

Sex Male Female

Date of birthDAY MONTH YEAR

Is this person currently, or have they ever been, a citizen of any country?

Yes Give details

From

From

To (If they still have the citizenship, write ‘Current’)

To (If they still have the citizenship, write ‘Current’)

DAY MONTH YEAR

DAY MONTH YEAR

No

When did this person have this citizenship?

When did this person have this citizenship?

Country

Country

1.

a.

l.

i.

k.

b.

c.

d.

e.

f.

g.

2.

Is this person of Arabic descent?

In English, write the full name of this person’s father’s father (ie. paternal grandfather)

No

Yes

Child

Family name

All given names including, if applicable, patronymic name (in English), clan and sub-clan names, and middle names

Is this person currently, or have they ever been, known by other names or spellings of their name?

No

Yes Give details in English

Type of name

Type of name

Family name

Family name

Given names

Given names

2.

1.Date of death (if deceased)

Note: You must give details for any person (living or deceased) who is or was your child. This should include, but is not limited to, natural children, adoptive children, step-children.

Provide details of one child at Question 57 and another at Question 58. If more than 2, give details at Part K – Additional details.

No

h. Does this person ever use a Chinese Commercial Code Number?

Yes Chinese Commercial Code Number (in full)

Examples of the types of other names:

• 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

j.

In English, provide their patronymic name

Is this person of Russian descent?

No

Yes

POSTCODE

Suburb and Town/City

State/Province/Region

Country

80 (Design date 11/13) - Page 18 © COMMONWEALTH OF AUSTRALIA, 2013

58Relationship to you (eg. son, daughter)

Country where this person lives now If in Australia, write the full address, if not living, write ‘DECEASED’

Place of birth

Sex Male Female

Date of birthDAY MONTH YEAR

Is this person currently, or have they ever been, a citizen of any country?

Yes Give details

From

From

To (If they still have the citizenship, write ‘Current’)

To (If they still have the citizenship, write ‘Current’)

DAY MONTH YEAR

DAY MONTH YEAR

No

When did this person have this citizenship?

When did this person have this citizenship?

Country

Country

1.

a.

l.

i.

k.

b.

c.

d.

e.

f.

g.

2.

Is this person of Arabic descent?

In English, write the full name of this person’s father’s father (ie. paternal grandfather)

No

Yes

Child

Family name

All given names including, if applicable, patronymic name (in English), clan and sub-clan names, and middle names

Is this person currently, or have they ever been, known by other names or spellings of their name?

No

Yes Give details in English

Type of name

Type of name

Family name

Family name

Given names

Given names

2.

1.

Date of death (if deceased)

No

h. Does this person ever use a Chinese Commercial Code Number?

Yes Chinese Commercial Code Number (in full)

Examples of the types of other names:

• 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

j.

In English, provide their patronymic name

Is this person of Russian descent?

No

Yes

POSTCODE

Suburb and Town/City

State/Province/Region

Country

80 (Design date 11/13) - Page 19© COMMONWEALTH OF AUSTRALIA, 2013

59

No Yes

No Yes

No Yes

No Yes

No Yes

No Yes

No Yes

No Yes

No Yes

No Yes

No Yes

If you answered ‘Yes’ to any of the questions at Question 59, 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, court details and dates of any period of imprisonment or other detention.

If insufficient space, give details at Part K – Additional details

Have you, or any other person included in this application, ever:

• been convicted of a crime or offence in any country (including any conviction which is now removed from official records)?

• been charged with any offence or have proceedings against you overseas or in Australia

• been acquitted of any criminal offence or other offence on the grounds of mental illness, insanity or unsoundness of mind?

• been confined in a prison or psychiatric institution by order of a court made in connection with criminal proceedings overseas or in Australia?

• been removed or deported from any country (including Australia)?

• left any country to avoid being removed or deported (including Australia)?

• been refused a visa for Australia or any other country?

• been excluded from or asked to leave any country (including Australia)?

• committed, or been involved in the commission of war crimes or crimes against humanity or human rights?

• been involved in any activities that would represent a risk to Australian national security?

• had any outstanding debts to the Australian Government or any public authority in Australia?

• been involved in any activity, or been convicted of any offence, relating to the illegal movement of people to any country (including Australia)?

• been associated with or involved in a program related to the development of weapons of mass destruction?

• been associated with or received training from an organisation engaged in violence, or been involved in an act of violence (including war, insurgency, freedom fighting, terrorism, protest) overseas or in Australia?

• been under a probation order, good behaviour bond, on parole, released on licence or subject to a periodic detention overseas or in Australia?

No Yes

Part I – Character details

No Yes

Signature of applicant

DateDAY MONTH YEAR

We strongly advise that you keep a copy of your application and all attachments for your records.

62

Part J – Declaration

I declare that:

• 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.

WARNING: Giving false or misleading information is a serious offence.

60

61

Are you currently, or have you been employed as an intelligence officer or an agent of an intelligence or security agency?

Have you ever had a visa cancelled by, been refused entry to, or been deported from, any country?

No

No

Yes

Yes

Give details of organisation, role and dates you served

Give details of dates, countries and circumstances.

If insufficient space, give details at Part K – Additional details

No Yes

No Yes

-

80 (Design date 11/13) - Page 20 © COMMONWEALTH OF AUSTRALIA, 2013

63

Part K – Additional details

Question number Additional information

If insufficient space, attach additional details