Form

Personal particulars for assessment

including character assessment 80
Department of Home Affairs

Important – Please read this information carefully before you Please open this form using Adobe Acrobat Reader.
complete this form. Once you have completed this form we Either type (in English) in the fields provided or print this form
strongly advise that you keep a copy for your records. and complete it (in English) using a pen and BLOCK LETTERS.
This form is to be completed in English by applicants who are Tick where applicable 3
16 years of age or over, as requested by the office processing the
application. If you need more space for any answers, give details at Part T –
Additional information
Integrity of application
The Department of Home Affairs (the Department) is committed
to maintaining the integrity of the visa and citizenship programs.
Please be aware that if you provide us with fraudulent documents Part A – Applicant details
or claims, this may result in processing delays and possibly your
application being refused. 1 Please provide your details as they appear in your official documents.
For example, passport, identity document, travel document, birth
Important information about privacy certificate.
The Privacy Act 1988 contains 13 Australian Privacy Principles Note: If you have one name only, please write it in the ‘Family name’
which regulate the way that the Department collects and handles field.
personal information. Information about how the Department Family name
collects, uses and discloses personal information for its key
functions can be found in form 1442i Privacy notice. More
information about the Department’s general information handling
All given names
practices (including form 1442i) can be found in the Department’s
Privacy policy at https://www.homeaffairs.gov.au/access-and-
accountability/our-commitments/privacy

Indeterminate /
Sex Male Female Intersex / Unspecified
Day Month Year
Day, month and year
Date of birth MUST be provided

Suburb of birth

Town/City of birth
State/Province/Region

Country

2 Do you ever use a Chinese Commercial Code Number for your names
shown in the passport/travel document at Question 1?
No
Yes Chinese Commercial Code Number (in full)

3 Are you of Russian descent?

No
Yes In English, provide your patronymic name

© COMMONWEALTH OF AUSTRALIA, 2021 80 (Design date 03/21) - Page 1

4 Have you been known by any other name(s)? Include: Part B – Passport / Travel document
• name at birth • cultural or tribal name or
• name before or after marriage clan/subclan name details
• adoptive or foster name • preferred name
9 Do you have a current passport or travel document?
• alias or pseudonym • other spellings of names
No Go to Question 13
No
Yes Give details
Yes Give details in English Passport/travel document number
Type of name
Family name Country of passport/travel document

Given names Day Month Year

Date of issue
Is this the original issue date?
If more than one name, give details at Part T – Additional information No Give original issue date
Day Month Year

5 Have you ever had a different date of birth to the one shown at
Question 1? Yes
No Day Month Year Day Month Year

Yes Different date of birth Date of expiry

6 Do you currently have citizenship from any country? Nationality

No, I am stateless Give details Place of issue/issuing authority

Name on the document (if the same as Question 1, write ‘SAME AS

QUESTION 1’)
Family name
Yes How did you gain this citizenship (eg. birth, descent,
naturalisation)?
Given names
Day Month Year

Date you gained this citizenship

7 Do you hold or have you held citizenship from any other country
(including dual citizenships and all previous citizenships)?
No
Yes Country

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

naturalisation)?

When did you have this citizenship?

Day Month Year Day Month Year

From to
Note: If you still have the citizenship, write ‘CURRENT’.
If more than one country, give details at Part T – Additional
information

8 Do you currently have permanent residency rights in any country other

than those declared in Questions 6 or 7?
No
Yes List all other countries

80 (Design date 03/21) - Page 2 © COMMONWEALTH OF AUSTRALIA, 2021

10 Do you have any other current passport or travel document? 13 Do you have, or remember, any of the document details?
No No
Yes Give details Yes Give as much information as possible
Passport/travel document number Passport/travel document number

Country of passport/travel document Country of passport/travel document

Day Month Year Day Month Year

Date of issue Date of issue

Date of expiry Date of expiry

Nationality Nationality
Place of issue/issuing authority Place of issue/issuing authority

Name on the document (if the same as Question 1, write ‘SAME AS Name on the document (if the same as Question 1, write ‘SAME AS
QUESTION 1’) QUESTION 1’)
Family name Family name

Given names Given names

11 Have you ever had any previous passports or travel documents

(including expired, lost or stolen documents)? Part C – Identity documents
No Go to Part C
14 Do you currently have, or have you ever had, any national identity
Yes
documents or numbers (including birth registration numbers, social
security cards etc)?
12 What happened to this document (Tick one only)
No
Expired
Yes Give details
Lost/stolen
Other
Give details Type of identification Identification number
Country of issue
document shown (if applicable)

© COMMONWEALTH OF AUSTRALIA, 2021 80 (Design date 03/21) - Page 3

 Part D – Address and contact details
15 Do you have any email addresses? 16 Do you have current contact telephone numbers?
Note: Include all personal, student and work email addresses. Do not No
include migration agent or legal practitioner email addresses. Yes Provide all telephone numbers
No Country code Area code Number
Yes Provide all of your email addresses Work ( ) ( )

Primary
Home ( ) ( )

Other
Mobile/cell

Other

17 Your address history for the last 10 years.

Note: If you are applying for a refugee/humanitarian visa, you must provide all addresses for the last 30 years.
Include:
• addresses inside and outside Australia
• places you resided for study/work
• refugee camps
• any other place you have resided such as share houses, university residences and temporary accommodation.
Note: Provide your address history in chronological order with no gaps in the timeline. If there are gaps, you must provide an explanation at Part T –
Additional information.
Date from Date to Full address (house number, street name, suburb, town/city, postcode) Country
Month Year Month Year

CURRENT

Part E – International travel / movements

18 Have you travelled to any country other than Australia in the last 10 years?
Note: If you are applying for a refugee/humanitarian visa, you must provide all visits to any country other than Australia for the last 30 years.
Include:
• work or study outside your usual country of residence
• holiday/leisure trips
• business
• military deployment
• visits back to your own country.
No
Yes Give details in chronological order
Date from Date to Reason for visit Country
Day Month Year Day Month Year

80 (Design date 03/21) - Page 4 © COMMONWEALTH OF AUSTRALIA, 2021

 Part F – Employment
19 Give details of all employment and unemployment
Employment includes: Unemployment includes:
• all paid employment • from date of birth up until first employment
• self-employment/family business • all gaps/breaks between employment
• work experience/internships • all gaps between education.
• unpaid employment/volunteer work.
If you are currently retired – write ‘CURRENTLY RETIRED’ in ‘Name of business’ field and provide details in the ‘Your occupation and duties’ field.
If you have never worked – write your date of birth in the ‘Date from’ field and ‘NEVER WORKED’ in the ‘Name of business/company’ field and provide details in the ‘Your occupation and duties’ field.
Note: Provide your employment and unemployment history with no gaps in the timeline. If there are gaps, you must provide an explanation at Part T – Additional information.
Date from Date to Your occupation and duties
Full address of business/company
Type of business OR
Name of business/company (Building number, street name, suburb,
(eg. government If unemployed/retired/never worked, Country
(no abbreviations) town/city, state/province)
Month Year Month Year department, bakery) provide details of how you occupied your time
(no Post Office box)
and financially supported yourself

CURRENT

© COMMONWEALTH OF AUSTRALIA, 2021 80 (Design date 03/21) - Page 5

 Part G – Education
20 Give details of all tertiary education and qualifications
Education/qualifications includes:
• college/vocational schools • specialist training
• university • skill/trade qualifications.
• research/thesis
Note: If you are applying for a Refugee and Humanitarian visa, you must provide details of all education and qualifications since birth.
Date from Date to Full name of institution Full name of course or description of research/
Course status Campus/address of institution Country
Month Year Month Year
(no abbreviations) Thesis and supervisor details (no abbreviations)
Completed
Withdrew
Currently enrolled
Completed
Withdrew
Currently enrolled
Completed
Withdrew
Currently enrolled
Completed
Withdrew
Currently enrolled
Completed
Withdrew
Currently enrolled
Completed
Withdrew
Currently enrolled
Completed
Withdrew
Currently enrolled
Completed
Withdrew
Currently enrolled
80 (Design date 03/21) - Page 6 © COMMONWEALTH OF AUSTRALIA, 2021
 Part H – Proposed travel or further stay
details
21 Are you currently in Australia?
No
Yes Go to Question 25

Proposed travel Further stay

22 Why are you travelling to Australia? 25 What is your main reason for remaining in Australia?
Include any relevant dates or events

26 List the towns/cities you will visit during your further stay in Australia
23 Do you have any proposed or booked travel dates for your journey to
Australia?
No
Yes Give details of proposed arrival in Australia
Day Month Year 27 Give details of your arrival in Australia
Arrival date Day Month Year

Arrival date
Flight number or vessel details (if known)
City of arrival

City of arrival
28 Are you applying for a temporary visa?
Give details of countries you will visit on your way to Australia No Go to Part I
(write ‘N/A’ if not applicable)
Yes

29 Do you have any proposed or booked travel for your departure from
Australia?
List the towns/cities you will visit during your time in Australia No
Yes Give details
Day Month Year

Departure date

24 Are you applying for a temporary visa? Flight number or vessel details (if known)
No Go to Part I
Yes Give details of proposed final departure from Australia
Day Month Year City of departure
Departure date Give details of countries you will visit after your departure from Australia
(write ‘N/A’ if not applicable)
Flight number or vessel details (if known)

City of departure
Give details of countries you will visit after your departure from Australia
(write ‘N/A’ if not applicable)

Now go to Part I

© COMMONWEALTH OF AUSTRALIA, 2021 80 (Design date 03/21) - Page 7

 Part I – Address(es) in Australia
30 Are you currently in Australia?
No
Yes Go to Question 33

Located outside Australia Located in Australia

31 Do you know any details of the places you will stay during your time in 33 Do you have any other addresses in Australia that have not been
Australia (eg. hotel, friends, relatives)? declared at Question 17?
No Go to Part J No Go to Part J
Yes Give the residential address and contact numbers Yes Give the residential address and contact numbers
Note: A post office box is not acceptable. Address (including hotel name and/or unit and building number and
Address (including hotel name and/or unit and building number and street name)
street name)

Suburb and town/city

Suburb and town/city

State or territory  Postcode

State or territory  Postcode
Telephone numbers
Telephone numbers
Office hours (Area code )
Office hours (Area code )
Mobile/cell
Mobile/cell
When and in what circumstances did you reside, or stay, at this
address?
32 Will you stay at any other address?
No Go to Part J
Yes Give the residential address and contact numbers
Address (including hotel name and/or unit and building number and
street name) If you have more than one other address in Australia that has not been
declared above or at Question 17, give details at Part T – Additional
information.

Suburb and town/city

State or territory  Postcode

Telephone numbers
Office hours (Area code )

Mobile/cell
If you will stay at any other address(es), give details at Part T –
Additional information.
Now go to Part J

80 (Design date 03/21) - Page 8 © COMMONWEALTH OF AUSTRALIA, 2021

 Part J – Australian visa history
34 Are you currently in Australia?
No
Yes Give details of current visa
Type of visa you hold Arrival date
Reason for journey Name used on entry Place of visa issue
(eg. visitor, business) Day Month Year

35 Have you been to Australia before?

No
Yes Give details of previous visas
Type of visa you held Arrival date Departure date
Reason for journey Name used on entry Place of visa issue
(eg. visitor, business) Day Month Year Day Month Year

© COMMONWEALTH OF AUSTRALIA, 2021 80 (Design date 03/21) - Page 9

 Part K – Character If you answered ‘Yes’ to any question at Question 36, give details,
including the date of the charge, the outcome and any penalty imposed.
Also attach court documents (for example sentencing remarks or court
36 Have you, or any other person included in this transcripts).
application, ever:
Where relevant, provide a copy of all declared orders (for example, any
• been charged with any offence that is domestic or family violence orders, child protection orders, or orders that
currently awaiting legal action? No Yes prohibit the applicant from having contact with another person for their
• been convicted of an offence in any country personal protection). You are only requested to declare an order where
(including any conviction which is now the applicant is the respondent or subject of the order. You are not asked
removed from official records)? No Yes to declare an order where the applicant is the person requiring personal
protection.
• been charged or convicted of family or
domestic violence offences or similar related
offences? No Yes
• been the subject of a domestic or family
violence order, or any other order, of a tribunal
or court or other similar authority, for the
personal protection of another person? No Yes
• been the subject of an arrest warrant or
Interpol notice? No Yes
• been found guilty of a sexually based offence
involving a child (including where no
conviction was recorded)? No Yes
• been named on a sex offender register? No Yes
• been acquitted of any offence on the grounds
of unsoundness of mind or insanity? No Yes
• been found by a court not fit to plead? No Yes
• been directly or indirectly involved in, or
associated with, activities which would
represent a risk to national security in
Australia or any other country? No Yes
• been charged with, or indicted for: genocide,
war crimes, crimes against humanity, torture,
slavery, or any other crime that is otherwise of
a serious international concern? No Yes
• been associated with a person, group or
organisation that has been/is involved in
criminal conduct? No Yes
• been associated with an organisation engaged
in violence or engaged in acts of violence
(including war, insurgency, freedom fighting,
terrorism, protest) either overseas or in
Australia? No Yes
• served in a military force, police force, state
sponsored/private militia or intelligence
agency (including secret police)? No Yes
• undergone any military/paramilitary training,
been trained in weapons/explosives or in the
manufacture of chemical/biological products? No Yes
• been involved in people smuggling or people
trafficking offences? No Yes
• been removed, deported or excluded from any
country (including Australia)? No Yes
• overstayed a visa in any country (including
Australia)? No Yes
• had any outstanding debts to the Australian
Government or any public authority in
Australia? No Yes

80 (Design date 03/21) - Page 10 © COMMONWEALTH OF AUSTRALIA, 2021

 Part L – Military service
37 Have you undertaken any military service?
Military service includes:
• compulsory • voluntary
• conscription • professional.
• military training
No Give reasons
Yes Give details in chronological order
Date from Date to Full name of Unit/
Country of
Country of service Battalion/Brigade Rank Duties
deployment
Day Month Year Day Month Year and Unit ID number

Part M – Employed by intelligence or Part O – Deportations

security agency 40 Have you ever been excluded, asked to leave, deported or removed from
any country?
38 Are you currently, or have you been employed as an intelligence
officer or an agent of an intelligence or security agency? No
No Yes Give details of dates, countries and circumstances
Yes Give details of organisation, role and dates you served

Part N – Visa refusals Part P – Citizenship refusals

39 Have you ever been refused a visa to any country? 41 Have you ever been refused, renounced or rescinded citizenship of any
No country?
Yes Give dates of refusal, countries and circumstances of No
refusal Yes Give dates of refusal, countries and circumstances of
refusal

© COMMONWEALTH OF AUSTRALIA, 2021 80 (Design date 03/21) - Page 11

 Part Q – Associated people
42 Do you have a partner?
Partner includes wife, husband, fiancé, boyfriend, girlfriend, significant other and de facto.
If widowed you must give details for your deceased partner.
No
Yes Give details
(If not living, write ‘DECEASED’ in ‘Country of current residence’ column)
Given names Any other names Sex Date of birth Chinese commercial codes
Relationship to you Family name
(include patronymic name) (eg. maiden or tribal name) M/F/X Day Month Year (If not applicable, write ‘N/A’)

Place of birth Country of current residence

Citizenship(s) and year granted Migrating with you?
Town/City State/Province/Region Country (If not living, write ‘DECEASED’)
No Yes

43 Do you have children?

Children includes biological or adopted, children from a current or previous marriage, all step-children and deceased children.
No
Yes Give details
(If not living, write ‘DECEASED’ in ‘Country of current residence’ column)

Child 1
Given names Any other names Sex Date of birth Chinese commercial codes
Relationship to you Family name
(include patronymic name) (eg. maiden or tribal name) M/F/X Day Month Year (If not applicable, write ‘N/A’)

Place of birth Country of current residence

Citizenship(s) and year granted Migrating with you?
Town/City State/Province/Region Country (If not living, write ‘DECEASED’)
No Yes

Child 2
Given names Any other names Sex Date of birth Chinese commercial codes
Relationship to you Family name
(include patronymic name) (eg. maiden or tribal name) M/F/X Day Month Year (If not applicable, write ‘N/A’)

Place of birth Country of current residence

Citizenship(s) and year granted Migrating with you?
Town/City State/Province/Region Country (If not living, write ‘DECEASED’)
No Yes

80 (Design date 03/21) - Page 12 © COMMONWEALTH OF AUSTRALIA, 2021

Child 3
Given names Any other names Sex Date of birth Chinese commercial codes
Relationship to you Family name
(include patronymic name) (eg. maiden or tribal name) M/F/X Day Month Year (If not applicable, write ‘N/A’)

Place of birth Country of current residence

Citizenship(s) and year granted Migrating with you?
Town/City State/Province/Region Country (If not living, write ‘DECEASED’)
No Yes

Child 4
Given names Any other names Sex Date of birth Chinese commercial codes
Relationship to you Family name
(include patronymic name) (eg. maiden or tribal name) M/F/X Day Month Year (If not applicable, write ‘N/A’)

Place of birth Country of current residence

Citizenship(s) and year granted Migrating with you?
Town/City State/Province/Region Country (If not living, write ‘DECEASED’)
No Yes

Child 5
Given names Any other names Sex Date of birth Chinese commercial codes
Relationship to you Family name
(include patronymic name) (eg. maiden or tribal name) M/F/X Day Month Year (If not applicable, write ‘N/A’)

Place of birth Country of current residence

Citizenship(s) and year granted Migrating with you?
Town/City State/Province/Region Country (If not living, write ‘DECEASED’)
No Yes

Child 6
Given names Any other names Sex Date of birth Chinese commercial codes
Relationship to you Family name
(include patronymic name) (eg. maiden or tribal name) M/F/X Day Month Year (If not applicable, write ‘N/A’)

Place of birth Country of current residence

Citizenship(s) and year granted Migrating with you?
Town/City State/Province/Region Country (If not living, write ‘DECEASED’)
No Yes
If more than 6 children, give details at Part T – Additional information

© COMMONWEALTH OF AUSTRALIA, 2021 80 (Design date 03/21) - Page 13

44 Do you know details of your parents?
Parents include biological parents, adopted parents, step parents, legal guardians and deceased parents.
No
Yes Give details
(If not living, write ‘DECEASED’ in ‘Country of current residence’ column)
Parent 1
Given names Any other names Sex Date of birth Chinese commercial codes
Relationship to you Family name
(include patronymic name) (eg. maiden or tribal name) M/F/X Day Month Year (If not applicable, write ‘N/A’)

Place of birth Country of current residence

Citizenship(s) and year granted Migrating with you?
Town/City State/Province/Region Country (If not living, write ‘DECEASED’)
No Yes

Parent 2
Given names Any other names Sex Date of birth Chinese commercial codes
Relationship to you Family name
(include patronymic name) (eg. maiden or tribal name) M/F/X Day Month Year (If not applicable, write ‘N/A’)

Place of birth Country of current residence

Citizenship(s) and year granted Migrating with you?
Town/City State/Province/Region Country (If not living, write ‘DECEASED’)
No Yes

Parent 3
Given names Any other names Sex Date of birth Chinese commercial codes
Relationship to you Family name
(include patronymic name) (eg. maiden or tribal name) M/F/X Day Month Year (If not applicable, write ‘N/A’)

Place of birth Country of current residence

Citizenship(s) and year granted Migrating with you?
Town/City State/Province/Region Country (If not living, write ‘DECEASED’)
No Yes

Parent 4
Given names Any other names Sex Date of birth Chinese commercial codes
Relationship to you Family name
(include patronymic name) (eg. maiden or tribal name) M/F/X Day Month Year (If not applicable, write ‘N/A’)

Place of birth Country of current residence

Citizenship(s) and year granted Migrating with you?
Town/City State/Province/Region Country (If not living, write ‘DECEASED’)
No Yes
If more than 4 parents, give details at Part T – Additional information
80 (Design date 03/21) - Page 14 © COMMONWEALTH OF AUSTRALIA, 2021
45 Do you have siblings?
Siblings include full, half and adopted brothers and sisters.
No
Yes Give details
(If not living, write ‘DECEASED’ in ‘Country of current residence’ column)

Sibling 1
Given names Any other names Sex Date of birth Chinese commercial codes
Relationship to you Family name
(include patronymic name) (eg. maiden or tribal name) M/F/X Day Month Year (If not applicable, write ‘N/A’)

Place of birth Country of current residence Migrating with you?

Citizenship(s) and year granted
Town/City State/Province/Region Country
No Yes

Sibling 2
Given names Any other names Sex Date of birth Chinese commercial codes
Relationship to you Family name
(include patronymic name) (eg. maiden or tribal name) M/F/X Day Month Year (If not applicable, write ‘N/A’)

Place of birth Country of current residence Migrating with you?

Citizenship(s) and year granted
Town/City State/Province/Region Country
No Yes

Sibling 3
Given names Any other names Sex Date of birth Chinese commercial codes
Relationship to you Family name
(include patronymic name) (eg. maiden or tribal name) M/F/X Day Month Year (If not applicable, write ‘N/A’)

Place of birth Country of current residence Migrating with you?

Citizenship(s) and year granted
Town/City State/Province/Region Country
No Yes

Sibling 4
Given names Any other names Sex Date of birth Chinese commercial codes
Relationship to you Family name
(include patronymic name) (eg. maiden or tribal name) M/F/X Day Month Year (If not applicable, write ‘N/A’)

Place of birth Country of current residence Migrating with you?

Citizenship(s) and year granted
Town/City State/Province/Region Country
No Yes
© COMMONWEALTH OF AUSTRALIA, 2021 80 (Design date 03/21) - Page 15
 Sibling 5
Given names Any other names Sex Date of birth Chinese commercial codes
Relationship to you Family name
(include patronymic name) (eg. maiden or tribal name) M/F/X Day Month Year (If not applicable, write ‘N/A’)

Place of birth Country of current residence Migrating with you?

Citizenship(s) and year granted
Town/City State/Province/Region Country
No Yes
If more than 5 siblings, give details at Part T – Additional information

46 Other travelling family members

Are there any other family members included in the visa application?
Family members include nieces, nephews, cousins, in-laws, grandparents etc. who are travelling with you
No
Yes Give details

Family member 1
Given names Any other names Sex Date of birth Chinese commercial codes
Relationship to you Family name
(include patronymic name) (eg. maiden or tribal name) M/F/X Day Month Year (If not applicable, write ‘N/A’)

Place of birth Country of current residence

Citizenship(s) and year granted
Town/City State/Province/Region Country

Family member 2
Given names Any other names Sex Date of birth Chinese commercial codes
Relationship to you Family name
(include patronymic name) (eg. maiden or tribal name) M/F/X Day Month Year (If not applicable, write ‘N/A’)

Place of birth Country of current residence

Citizenship(s) and year granted
Town/City State/Province/Region Country

If more than 2 other family members, give details at Part T – Additional information

80 (Design date 03/21) - Page 16 © COMMONWEALTH OF AUSTRALIA, 2021

47 Do you have any personal contacts in Australia? 48 Do you have any other personal contacts in Australia?
Personal contacts include visa sponsors, any relatives, friends, family No Go to Part R
members and acquaintances in Australia. Yes Give details
No Go to Part R Family name
Yes Provide as much information about one of your personal
contacts as possible
Family name Given names

Given names Indeterminate /

Sex Male Female Intersex / Unspecified
Relationship to you (eg. partner, sister, aunt, friend)
Indeterminate /
Sex Male Female Intersex / Unspecified
Relationship to you (eg. partner, sister, aunt, friend) Day Month Year

Date of birth

Day Month Year Town/City of birth

Date of birth State/Province/Region
Town/City of birth
State/Province/Region Country

Nationality
Country Your personal contact’s current residential address
Note: A post office box is not acceptable.
Nationality
Address (including building/unit/house number and street name)
Your personal contact’s current residential address
Note: A post office box is not acceptable.
Address (including building/unit/house number and street name)

Suburb and town/city

Suburb and town/city State or territory Postcode


Telephone numbers
State or territory Postcode Office hours (Area code )

Telephone numbers Mobile/cell
Office hours (Area code )
Email address
Mobile/cell Give details of all other contacts at Part T – Additional information
Email address

© COMMONWEALTH OF AUSTRALIA, 2021 80 (Design date 03/21) - Page 17

 Part R – Sponsoring employer details Part S – Declaration
WARNING: Giving false or misleading information is a serious offence.
49 Are you being sponsored by, or associated with, a business or
organisation in Australia? 53 I declare that:
No Go to Part S • the information I have supplied in or with this form is complete,
Yes Give details correct and up-to-date in every detail.
Organisation/Business name • I have read and understand the information supplied to me.
• I have read the information contained in form 1442i Privacy notice.
• I understand the Department may collect, use and disclose my
Organisation/Business description personal information (including biometric information and other
sensitive information) as outlined in form 1442i Privacy notice.

Signature of
applicant
Organisation/Business commercial address (including building number -
and street name) Day Month Year

Date

We strongly advise that you keep a copy of your application

and all attachments for your records.
Suburb and town/city

State or territory  Postcode

Name of contact person in business/organisation

50 Does the employer/business have any other associated addresses?

No
Yes Give details
Type of address (eg. head office, factory, retail store)

Address (including building number and street name)

Suburb and town/city

State or territory  Postcode

51 Does the employer/business have an email address?

No
Yes Give details

52 Does the employer/business have telephone numbers?

No
Yes List all contact telephone numbers (including area code)

80 (Design date 03/21) - Page 18 © COMMONWEALTH OF AUSTRALIA, 2021

 Part T – Additional information
54 Question
Additional information
number

If you do not have enough space to give all the necessary information, attach a separate statement to this form with further details
© COMMONWEALTH OF AUSTRALIA, 2021 80 (Design date 03/21) - Page 19