PAGE 6/16

Contact detail

Country of residence

Department office:

The applicant may be required to attend an Australlian government office for an interview.Which is the
closest office to the applicant current location?

Office:

Residential address:

Note that a street address is required . A post office address cannot be accepted as a residential address:

Country:_

Address:

Surburb/ town:

State/province

Postal code

Is the postal address the same as residential address ____Y or _____N

Contact telephone numbers

Enter numbers only with no spaces

Home phone

Business phone

Mobile/ cell phone

Email address

Email address
PAGE 7/16

Authorised recipent:

Does the applicant authorise another person to receive correspondence on their behalf?

This authorises the department to sendthe authorised person all written correspondencethat would
otherwise be sent directly to the applicant

No

Yes, a migration agent

Yes, another person

The person is prefer to as the ‘ authorised recipent’

Electronic communication

The Department prefer to communicateelectronicallyas this provides a faster method of

communication.

All correspondence, including notificationof the outcome of the application will be sent to

Email address:

Note : the holder of this email address may receive a verification email from the Department if the
address has not already been verified. If the holder receive a verification email, they should lick on the
link to verify their address before this application is submitted.
Page 9/16

Education

Does the applicant meet the education requirements for this visa?

Yes
No
Give details of all past and current studies undertaken at secondary level or above

ADD

Qualification:

Course name:

Institution:

Country of institution:

Date from:

Date to:

Status :
Page 10/16

Usual occupation

Usual occupation

Intended emlyment

Industry type
Page 11/16

Language

Does this applicant hold a current passport from the USA, UK, Canada, New zealand, or the republic of
Ireland ? Yes No

Does this applicant has at least funtional English language ability?

Yes No

Select the options which represent proof the applicant having functional English

1. Completion of an English language proficiency test of at least functional level within the last
12 month.

2. Completed all years of primary education and at least 3 years of secondary education
at educational institutions in which all instruction was conducted in English

3. Completed at least 5 years of secondary education at institutions in which all instruction

was conducted in English

4. Completed, in Australia, at least 1 year of full-time study or equivalent part-time study

towards a degree, higher degree, diploma, or associate diploma, at an institution or institutions
where all instruction was conducted in English

5. Successfully completed the 'Bagrut Exam' in the level of 3 study units

6. Other
English test details
Give details of the most recent English test:
Name of test:
Date of test:
Test reference number:
Country where test was undertaken:
Language ability:
Main Language
Main language:
Page 13/16

Health declarations

In the last five years. has any applicant visited. or lived. outside their country of passport. for more than
3 consecutive months? Do not include time spent in Australia. Yes or No

Does any applicant intend to enter a hospital or a health care facility (including nursing homes) while in
AuStralia? Yes or No

Does any applicant intend to work as. or study to be a doctor, dentist nurse or paramedic during their
stay in Australia? Yes or No

Does any applicant intend to work Or be a trainee at a child care centre (including preschools and
creches) while in Australia? Yes or No

Does any applicant intend to be in a classroom situation for more than 3 months (eg as either a student,
teacher lecturer or observer)? Yes or No

Has any applicant

• ever had or currently have tuberculosis?

• been rt close contact with a family member that has active tuberculosis?

• ever had a chest x-ray which showed an abnormahty?

Yes or No

During their proposed visa to Australia does any applicant expect to incur medical costs or require
treatment or medical follow up for

 blood disorder cancer

 heart disease
 hepatitis B or C and'ix liver disease
 HIV infection, including AIDS
 lodney disease including dialysis
 mental illness pregnancy
 respiratory disease that has required hOspital admission or oxygen therapy
 other?

Yes or No

Does any applicant require assistance with mobility or care due to a medical condition?

Yes or No
Page 14/16

Character declarations

If the applicant answers 'Yes' to any of the character declarations they must give all relevant details. For
combined applications, state which applicant the declaration applies to.

If the matter relates to a criminal conviction. provide

• the date and nature of the offence

• full details of the sentence

• dates of any period of imprisonment or other detention

Has any applicant ever been charged with any offence that is currently awaiting legal action?

Yes or No

Has any applicant ever been convicted of an offence in any country (including any conviction which is
now removed from official records)?

Yes or No

Has any applicant ever been the subject of an arrest warrant or Interpol notice?

Yes or No

Has any applicant ever been found guilty of a sexually based offence involving a child (including where
no conviction was recorded)?

Yes or No

Has any applicant ever been named on a sex offender register?

Yes or No

Has any applicant ever been acquitted of any offence on the grounds of unsoundness of mind or
insanity?

Yes or No

Has any applicant ever been found by a court not fit to plead?

Yes or No

Has any applicant ever been directly or indirectly involved in or associated with activities which would
represent a risk to national security in Australia or any other country? Yes or No

Has any applicant ever been charged with, or indicted for genocide. war crimes. crimes against humanity
torture. slavery. or any other crime that is otherwise of a serious international concern? Yes or No
Has any applicant ever been associated with a person. group or organisation that has been or is involved
in criminal conduct? Yes or No

Has any applicant ever been associated with an organisation engaged in violence or engaged in acts of
violence (including war insurgency freedom fighting terronsm protest) either overseas or in Australia?
Yes or No

Has any applicant ever served in a military force. police force, state sponsored / private militia or
intelligence agency (including secret police)?

Yes or No

Has any applicant ever undergone any military/paramilitary training been trained in weapons/explosives
or in the manufacture of chemicalithological products?

Yes or No

Has any applicant ever been involved in people smuggling or people trafficking offences?

Yes or No

Has any applicant ever been removed. deported or excluded from any country (including Australia)?

Yes or No

Has any applicant ever had any outstanding debts to the Australian Government or any public authority
in Australia?

Yes or No
Page 15/16

Work and Holiday declarations

Warning:

Giving false or misleading information is a serious offence.

The applicant declares that they

Understand that they must abide by the conditions of the visa: Yes No

Understand that the visa they are applying for does not permit them to be employed in Australia with
one employer for more than 6 months without prior permission.

• Yes ' No

Understand that the visa they are applying for does not permit them to undertake studies or training for
more than 4 months.

• Yes No

Have sufficient funds for the initial period of their stay in Australia and for the fare to their intended
overseas destination on leaving Australia.

• Yes No

Understand that any employment is incidental to their holiday in Australia and the purpose of working is
to supplement their holiday funds.

• Yes No
Page 16/16

Declarations

Warning:

Giving false or misleading information is a serious offence.

The applicants declare that they:

Have read and understood the information provided to them in this application

Yes or No

Have provided complete and correct information in every detail on,this form and on any attachments to
it.

Yes or No

Understand that if any fraudulent documents or false or misleading information has been provided with
this application. or if any of the applicants fail to satisfy the Minister of their identity. the application
may be refused and the applicant(s) and any member of their family unit may become unable to be
granted a visa for a specified period of time

yes or No

Understand that if documents are found to be fraudulent or information to be incorrect after the grant
of a visa. the visa may subsequently be cancelled.

Yes No

Understand that if this application is approved any person not included in this application will not have
automatic right of entry to Australia.

Yes No

Will inform the Department in writing immediately as they become aware of a change in circumstances
(including change of address) or if there is any change relating to information they have provided in or
with this application. while it is being considered. Yes No

Have read the information contained in the Pnvacy Notice (Form 14470I) Yes No

Understand that the department may collect. use and disclose the applicant's personal information
(including biometric information and other sensitive information) as outlined in the Privacy Notice (Form
14421)

Yes No

Give consent to the collection of their fingerprints and facial image if required

Yes No

Understand that if required to provide their fingerprints and facial image. the applicant's fingerprints
and facial image and biographical information held by the Department may be given to Australian law
enforcement agencies to help identify the applicant and determine eligibility for grant of the visa being
applied for and for law enforcement purposes.

Yes No

Give consent to Australian law enforcement agencies disclosing the applicant's biometric biographical
and criminal record information to the Department to help identify the applicant to determine eligibility
for grant of a visa and for law enforcement purposes.

Yes No

Give consent to the Department using the applicant's biometric biographical and criminal record
information obtained for the purposes of the Migration Act 1958 or the Citizenship Act 2007

Yes No

Australian values

Each applicant who is 18 years or over has read or had explained to them information provided by the
Australian Government on Australian society and values and agrees to the Australian values statement

Yes No