OFFICIAL: Sensitive

Personal Privacy

Department of Home Affairs Record of

My Health Declarations Responses

Terms and Conditions

View Terms and Conditions View Privacy statement
I have read and agree to the terms and conditions
Yes
Application context

Visa details

Give details of the visa subclass for which the applicant intends to apply.

Visa subclass: TEMPORARY SKILL SHORTAGE - 482

Has the applicant already submitted a visa application for this subclass and are they waiting for a
decision to be made by the Department on that application?
No

Primary applicant

Passport details
Enter the following details as they appear in the applicant's personal passport.
Family name: Patel
Given names: Shaileshbhai Manilal
Sex: Male
Date of birth: 22 Oct 1974
Passport number: Y5411504
Country of passport: INDIA - IND
Nationality of passport holder: INDIA - IND
Date of issue: 04 Jul 2023
Date of expiry: 03 Jul 2033

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OFFICIAL: Sensitive
This form submitted by : [email protected]
Role(s) : Self-registered user
Submitted on : 19/10/2024 04:25

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Place of issue / issuing Ahmedabad

authority:
National identity card

Does this applicant have a national identity card?

Yes

National identity card

Enter details exactly as shown on the national identity card.
Family name: Patel
Given names: Shaileshbhai Manilal
Identification number: Y5411504
Country of issue: INDIA
Note: If the National identity card does not have a Date of issue or a Date of expiry, do not enter a
date. Leave the field/s blank.
Date of issue: 04 Jul 2023
Date of expiry: 03 Jul 2033
Place of birth

Town / City: Gaglasan , Patan

State / Province: Gujarat
Country of birth: INDIA
Relationship status

Relationship status: Married

Other names / spellings

Is this applicant currently, or have they ever been known by any other names?
No
Citizenship

Is this applicant a citizen of the selected country of passport (INDIA)?

Yes
Is this applicant a citizen of any other country?
No
Other passports

Does this applicant have other current passports?

No
Other identity documents

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Does this applicant have other identity documents?

No
Additional identity questions
Provide further details below, where available.
Previous travel to Australia

Has this applicant previously travelled to Australia or previously applied for a visa?
No
Contact details

Country of residence

Usual country of residence: INDIA

Residential address
Note that a street address is required. A post office address cannot be accepted as a residential
address.
Country: INDIA
Address: B 306 Himshila Residency , near
Shamrudhadh sky , vastral , Ahmedabad
Suburb / Town: Vastral
State or Province: GUJARAT
Postal code: 382418
Contact telephone numbers
Enter numbers only with no spaces.
Home phone: 9426527007
Business phone: 9426527007
Mobile / Cell phone: 9426527007
Postal address

Is the postal address the same as the residential address?

Yes

Electronic communication
The Department prefers to communicate electronically as this provides a faster method of
communication.
All correspondence, including notification of the outcome of the application will be sent to:
Email address: [email protected]

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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 address holder receives a verification email, they should
click on the link to verify their address before this application is submitted.

Accompanying members of the family unit

Are there any accompanying members of the family unit included in this application?
Yes

Accompanying member of the family unit

Relationship to primary applicant

Relationship to the primary Spouse/De Facto Partner

applicant:

Passport details
Enter the following details as they appear in the family member's passport.

Family name: Patel

Given names: Bhavnaben Shaileshbhai
Sex: Male
Date of birth: 01 Jun 1976
Passport number: X4774358
Country of passport: INDIA - IND
Nationality of passport holder: INDIA - IND
Date of issue: 24 Apr 2024
Date of expiry: 23 Apr 2034
Place of issue / issuing Ahmedabad
authority:

National identity card

Does this family member have a national identity card?

Yes

National identity card

Enter details exactly as shown on the national identity card.
Family name: Patel
Given names: Bhavnaben Shaileshbhai
Identification number: X4774358

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Country of issue: INDIA

Note: If the National identity card does not have a Date of issue or a Date of expiry, do not enter a
date. Leave the field/s blank.
Date of issue: 24 Apr 2024
Date of expiry: 23 Apr 2034
Place of birth

Town / City: Kamalpur

State / Province: Gujarat
Country of birth: INDIA
Relationship status

Relationship status: Married

Other names / spellings

Is this family member currently, or have they ever been known by any other names?
No
Citizenship

Is this family member a citizen of the selected country of passport (INDIA)?

Yes
Is this family member a citizen of any other country?
No
Other passports

Does this family member have other current passports?

No
Other identity documents

Does this family member have other identity documents?

No
Grant number

Does this applicant have an Australian visa grant number?

No

Contact details

Are the contact details the same as for the primary applicant?
No
Country of residence

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Usual country of residence: INDIA

Residential address
Note that a street address is required. A post office address cannot be accepted as a residential
address.
Country: INDIA
Address: B 306 , himshila residency, near
Shamrudhadh sky vastral , Ahmedabad
Suburb / Town: Vastral
State or Province: GUJARAT
Postal code: 382418
Contact telephone numbers
Enter numbers only with no spaces.
Home phone: 9426527007
Business phone: 9426527007
Mobile / Cell phone: 9426527007
Postal address

Is the postal address the same as the residential address?

Yes

Electronic communication
The Department prefers to communicate electronically.
All relevant correspondence will be sent to the email address provided below.
Email address: [email protected]

Travel details

Travel details - PATEL, SHAILESHBHAI MANILAL

Previous travel to Australia

Has the applicant been in Australia in the last 28 days?

No
Details of stay

Length of time the applicant Over 12 months

intends to stay in Australia on
the above visa subclass:

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Travel details - PATEL, BHAVNABEN SHAILESHBHAI

Previous travel to Australia

Has the applicant been in Australia in the last 28 days?

No
Details of stay

Length of time the applicant Over 12 months

intends to stay in Australia on
the above visa subclass:
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.
No
Does any applicant intend to enter a hospital or a health care facility (including nursing homes) while
in Australia?
No
Does any applicant intend to work as, or study or train to be, a health care worker or work within a
health care facility while in Australia?
No
Does any applicant intend to work, study or train within aged care or disability care while in Australia?
No
Does any applicant intend to work or be a trainee at a child care centre (including preschools and
creches) while in Australia?
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)?
No
Has any applicant:
• ever had, or currently have, tuberculosis?
• been in close contact with a family member that has active tuberculosis?
• ever had a chest x-ray which showed an abnormality?
No
During their proposed visit 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/or liver disease
• HIV infection, including AIDS
• kidney disease, including dialysis

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• mental illness
• pregnancy
• respiratory disease that has required hospital admission or oxygen therapy
• other?
No
Does any applicant require ongoing medical care or need special equipment, assistive technology or
assistance from others for daily living?
No
Declarations
Warning:
Giving false or misleading information is a serious offence.

The applicant declares that the individuals listed in this form:

Have read and understood the information available to them within this form, as well as information
available on the website of the Department about the My Health Declarations service and when it is
recommended to be used.
Yes
Have provided complete and correct information in every detail when completing this form.
Yes
Understand that if any of the information provided within this form changes, this may impact
which health examinations they are required to undergo, and that if they subsequently apply for
an Australian visa application, the Department of Home Affairs, its approved panel physicians or
onshore service provider may request additional health examinations be undertaken.
Yes
Understand that if any fraudulent or misleading information is found, any future visa application(s)
may be refused and/or any visa subsequently cancelled.
Yes
Will inform the Department in writing immediately as they become aware of a change in
circumstances (including a change in address) or if there is any change relating to the information
they have provided within this form, prior to any associated visa application being finalised.
Yes
Have read the information contained in the Privacy Notice(Form 1442i).
Yes
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 1442i).
Yes
Consent to all medical information being submitted to the department for the purposes of
assessing their health for current or future Australian visa applications, and being transferred to the
department's electronic health processing system known as eMedical.
Yes

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Consent to all medical information being available to the panel clinic(s) and/or the department's
migration medical services provider so that immigration health examinations can be undertaken via
the eMedical system.
Yes
We strongly advise the applicant(s) print and take a copy of the application to the health examination
appointment.

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