form including character assessment 80 · 2020-01-16 · including character assessment form 80...
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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
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