New editable form 80
19
80 (Design date 04/12) - Page 1 © COMMONWEALTH OF AUSTRALIA, 2012 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 Citizenship (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 is authorised to collect information provided on this form under Part 2 of the Migration Act 1958 ‘Control of Arrival and Presence of Non-Citizens’. 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 ✓ Tick where applicable Please use a pen, and write neatly in English using BLOCK LETTERS. Place of birth Town/city Country 1 Give details as they appear on your current passport or the travel document that you will use to enter Australia 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
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Transcript of New editable form 80
80 (Design date 04/12) - Page 1© COMMONWEALTH OF AUSTRALIA, 2012
Personal particulars for assessmentincluding 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 Citizenship (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 is authorised to collect information provided on this form under Part 2 of the Migration Act 1958 ‘Control of Arrival and Presence of Non-Citizens’. 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
✓Tick where applicable
Please use a pen, and write neatly in English using BLOCK LETTERS.
Place of birth
Town/city
Country
1 Give details as they appear on your current passport or the travel document that you will use to enter Australia
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
80 (Design date 04/12) - Page 2 © COMMONWEALTH OF AUSTRALIA, 2012
2 Does the passport/travel document at Question 1 show your full name?
No
No
Yes
Yes
What is your full name?
Go to Question 5
Write the number of the document you used to enter Australia
Family name
Given names (including patronymic name in English)
3
4
5
6
8
9
7
Are you currently in Australia?
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 an alternative 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
No
Yes
Yes
Yes
Yes
Yes
Yes
Did you use the passport/travel document at Question 1 to enter Australia?
Chinese Commercial Code Number
In English, write the full name of your father’s father (ie. your paternal grandfather)
Give details in English
Alternative 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 J
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
• patronymic name
• other spellings of names
80 (Design date 04/12) - Page 3© COMMONWEALTH OF AUSTRALIA, 2012
10 11
12
13
Do you currently have, or have you ever had, other passports/travel documents?
Are you currently, or have you ever been, a citizen of any other country not already shown at Question 1 or Question 10?
Do you currently have permanent residence rights in any country not already shown at Question 1, Question 10 or Question 11?
Have you ever been refused citizenship of any country?
No No
No
No
Yes Yes
Yes
Yes
Give details as they appear on the other passports/travel documents (If more than one, give details at Part J)
Give 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
Reason for refusal
Reason for refusal
Are you, or have you ever been, a citizen of the country of passport/travel document shown above?
Date of issue
From
From
From
Date
Date
Date of expiry
To (If you still have the citizenship, write ‘Current’)
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
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)?
How did you gain this citizenship (eg. birth, descent, naturalisation)?
When did you have this citizenship?
When did you have this citizenship?
When did you have this citizenship?
If more than 2, give details at Part J
Country
Country
Country
Country
Country
Country
1.
1.
1.
2.
2.
2.
If more than 2, give details at Part J
80 (Design date 04/12) - Page 4 © COMMONWEALTH OF AUSTRALIA, 2012
14
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
Attach certified copies of original documents and English translations
15 Details of your place of birth
State/Province/Region
Town/city
Suburb (if applicable)
Country
16
19
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.
Address in Australia where you can be contacted or will be stayingNote: A post office box or mailbox address is not acceptable.
Attach certified copies of original documents and English translations that give evidence of your address
POSTCODE
Unit/Apartment number
Postal code
Address
Country
State/Province/Region
Suburb/Town/City
17 Do you have an e-mail address?Note: Do not provide the email address of a migration agent.
No
Yes E-mail address
18
20
Your current contact numbers (include country code if outside Australia)
Contact telephone numbers in Australia (if known)
( )
( )
( )
( )
( )
( )
COUNTRY CODE
AREA CODE
AREA CODE
Work
Work
Home
Home
Mobile/cell
Mobile/cell
( ) ( )
( )
( ) ( )
( )
( ) ( )Fax
Other contact numbers you have
Other contact numbers
NUMBER
NUMBER
80 (Design date 04/12) - Page 5© COMMONWEALTH OF AUSTRALIA, 2012
21 Do you have personal contacts in Australia (including business contacts/sponsor)?
No
Yes Give details
Go to Part C
Given names
Given names
Family name
Sex
Sex
Male
Male
Female
Female
Date of birth
Date of birth
Relationship to you (eg. partner, sister, aunt, friend, business contact/sponsor)
Relationship to you (eg. partner, sister, aunt, friend, business contact/sponsor)
( )
( )
AREA CODE
AREA CODE
NUMBER
NUMBER
Telephone number
Telephone number
Family name
1.
2.
If more than 2, give details at Part J
DAY MONTH YEAR
DAY MONTH YEAR
26 Your partner’s place of birth
State/Province/Region
Town/city
Suburb (if applicable)
Country
Family name
All given names
23 Your partner’s full name
Part B – Your partner’s details
24
25
Sex Male Female
Date of birth
Date of death (if deceased)
DAY MONTH YEAR
27 Is your partner currently, or have they ever been, a citizen of any country?
No
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 J
Country
Country
1.
2.
28 Does your partner ever use a Chinese Commercial Code Number for names shown at Question 23
No
Yes Chinese Commercial Code Number
22 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 YEAR
Note: If you are widowed, you must give details for your deceased partner.
80 (Design date 04/12) - Page 6 © COMMONWEALTH OF AUSTRALIA, 2012
30 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 J
31
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
Attach certified copies of original documents and English translations
29 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
• patronymic name
• other spellings of names
80 (Design date 04/12) - Page 7© COMMONWEALTH OF AUSTRALIA, 2012
Go to Part D
Proposed final departure details
33
35
36
Are you currently in Australia?
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
No
Yes
Yes
Part C – Travel to Australia
Departure date
Flight number or vessel details (if known)
DAY MONTH YEAR
Place of departure
City
State
Proposed arrival details34
Arrival date
Date of birth
Date of birth
Flight number or vessel details (if known)
Citizenship
Citizenship
DAY MONTH YEAR
DAY MONTH YEAR
DAY MONTH YEAR
Place of arrival
City
State
Go to Part E
32 Are you travelling, or did you travel to Australia 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 J
80 (Design date 04/12) - Page 8 © COMMONWEALTH OF AUSTRALIA, 2012
Go to Part E
Give details
37
42
Do you currently hold an Australian visa?
Have you been given an additional period of stay in Australia with this visa?
No
No
Yes
Yes
Part D – Current visa details
Details of your arrival in Australia
Final date you must leave Australia on this visa
40
41
Arrival date
Date of issue
DAY MONTH YEAR
DAY MONTH YEAR
DAY MONTH YEAR
Place of arrival
City
State
NOTE: Only complete this Part if you are currently in Australia
38
39
Visa details
Country where you lived when you were issued this visa
Type of visa
Visa conditions (if applicable)
Visa number
V <
80 (Design date 04/12) - Page 9© COMMONWEALTH OF AUSTRALIA, 2012
DAY MONTH YEAR
Date from
Date from
Date to
Date to
DAY MONTH YEAR
43
44
45
Have you travelled to Australia before?
Have you travelled to any countries other than Australia (including short stays) during the last 10 years?
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 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 J)
Country or countries
Country
DAY MONTH YEAR
Date from Date to
DAY MONTH YEARYour names shown on visa
Country where you lived when visa was issued
Type of visa (eg. visitor, student, business) Reason for visit
Reason for visit
Full address (number, street name, suburb, state/province, country)
Give details in chronological order (If insufficient space, give details at Part J)
Give details in chronological order (If insufficient space, give details at Part J)
No
No
Yes
Yes
Part E – Other information
MONTH YEAR MONTH YEAR
80 (Design date 04/12) - Page 10 © COMMONWEALTH OF AUSTRALIA, 2012
46 Give details of your employment history for the entire time since leaving school, including periods of unemployment. (If insufficient space, give details at Part J)
Name and address of employer/business Employer’s contact number Type of business Your position/title/dutiesDate from Date toMONTH YEAR MONTH YEAR
48
47
Have you had any military service?
Are you currently unemployed?
DAY MONTH YEAR
Date from Date toDAY MONTH YEAR
RankFull name of Unit/Battalian/BrigadeCountry Duties
Give details in chronological order (If insufficient space, give details at Part J)
Give details of how you financially support yourself, including how long you have received this support for and how much you receive on a monthly basis
No
No
Yes
Yes
80 (Design date 04/12) - Page 11© COMMONWEALTH OF AUSTRALIA, 2012
49 Have you undertaken any qualifications since secondary school (including courses completed, withdrawn or continuing)? (If insufficient space, give details at Part J)
Name and address of institutionCountry Course of studyDid you complete the course,
withdraw or currently enrolled?Date from Date to
MONTH YEAR MONTH YEAR
Completed course
Withdrew
Currently enrolled
Completed course
Withdrew
Currently enrolled
Completed course
Withdrew
Currently enrolled
Completed course
Withdrew
Currently enrolled
Completed course
Withdrew
Currently enrolled
50 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
Given names
80 (Design date 04/12) - Page 12 © COMMONWEALTH OF AUSTRALIA, 2012
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 J.
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
Parent’s place of birth
State/Province/Region
Town/city
Country
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.
k.
i.
j.
b.
c.
d.
e.
f.
g.
2.
Is this parent of Arabic descent?
In English, write the full name of your parent’s father’s father (ie. paternal grandfather)
No
No
Yes
Parent
Your parent’s full name
Family 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, National Identity Number and/or Birth Registry Number?
Yes Give details
Type of number (eg. birth registry number)
Type of number (eg. birth registry number)
2.
1.
Suburb (if applicable)
Date of death (if deceased)
Number
Number
1.
2.
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
• patronymic name
• other spellings of names
80 (Design date 04/12) - Page 13© COMMONWEALTH OF AUSTRALIA, 2012
52Relationship to you (eg. natural parent, step-parent etc)
Parent’s place of birth
State/Province/Region
Town/city
Country
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.
b.
c.
d.
e.
f.
g.
2.
Parent
Your parent’s full name
Family name
All given names including, if applicable, patronymic name (in English), clan and sub-clan names, and middle names
Suburb (if applicable)
Date of death (if deceased)
Country where this parent lives now If in Australia, write the full address, if not living, write ‘DECEASED’
k.
i.
j.
Is this parent of Arabic descent?
In English, write the full name of your parent’s father’s father (ie. paternal grandfather)
No
No
Yes
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, National Identity Number and/or Birth Registry Number?
Yes Give details
Type of number (eg. birth registry number)
Type of number (eg. birth registry number)
2.
1.
Number
Number
1.
2.
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
• patronymic name
• other spellings of names
80 (Design date 04/12) - Page 14 © COMMONWEALTH OF AUSTRALIA, 2012
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
State/Province/Region
Town/city
Country
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.
k.
i.
j.
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.
Suburb (if applicable)
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 J.
No
h. Does this person ever use a Chinese Commercial Code Number?
Yes Chinese Commercial Code Number
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
• patronymic name
• other spellings of names
80 (Design date 04/12) - Page 15© COMMONWEALTH OF AUSTRALIA, 2012
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
State/Province/Region
Town/city
Country
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.
k.
i.
j.
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.
Suburb (if applicable)
Date of death (if deceased)
No
h. Does this person ever use a Chinese Commercial Code Number?
Yes Chinese Commercial Code Number
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
• patronymic name
• other spellings of names
80 (Design date 04/12) - Page 16 © COMMONWEALTH OF AUSTRALIA, 2012
55Relationship to you (eg. brother, sister, step-brother, step-sister)
Place of birth
State/Province/Region
Town/city
Country
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.
b.
c.
d.
e.
f.
g.
2.
Brother or sister
Family name
All given names including, if applicable, patronymic name (in English), clan and sub-clan names, and middle names
Suburb (if applicable)
Date of death (if deceased)
No
h. Does this person ever use a Chinese Commercial Code Number?
Yes Chinese Commercial Code Number
Country where this person lives now If in Australia, write the full address, if not living, write ‘DECEASED’
k.
i.
j.
Is this person of Arabic descent?
In English, write the full name of this person’s father’s father (ie. paternal grandfather)
No
Yes
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.
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
• patronymic name
• other spellings of names
80 (Design date 04/12) - Page 17© COMMONWEALTH OF AUSTRALIA, 2012
56Relationship to you (eg. brother, sister, step-brother, step-sister)
Place of birth
State/Province/Region
Town/city
Country
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.
b.
c.
d.
e.
f.
g.
2.
Brother or sister
Family name
All given names including, if applicable, patronymic name (in English), clan and sub-clan names, and middle names
Suburb (if applicable)
Date of death (if deceased)
No
h. Does this person ever use a Chinese Commercial Code Number?
Yes Chinese Commercial Code Number
Country where this person lives now If in Australia, write the full address, if not living, write ‘DECEASED’
k.
i.
j.
Is this person of Arabic descent?
In English, write the full name of this person’s father’s father (ie. paternal grandfather)
No
Yes
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.
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
• patronymic name
• other spellings of names
80 (Design date 04/12) - Page 18 © COMMONWEALTH OF AUSTRALIA, 2012
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No
No
No
No
Yes
Yes
Yes
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 above questions, you must state who it applies to and give ALL relevant details. If the matter relates to a criminal conviction, please give the nature of the offence, full details of sentence and dates of any period of imprisonment or other detention.
If insufficient space, give details at Part J
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 that is currently awaiting legal action?
• been acquitted of any criminal offence or other offence on the grounds of mental illness, insanity or unsoundness of mind?
• 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?
• Are you, or any other person included in this application, presently 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 H – 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.
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Part I – 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.
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59
Are you currently, or have you been employed as an intelligence officer or an agent of an intelligence or security agency?
Have you ever been denied or refused a visa or entry to another country?
No
No
Yes
Yes
Give details of organisation, role and dates you served
Give details
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Part J – Additional details
Question number Additional information
(If insufficient space, attach additional details)
