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Personal particulars for assessment including character assessment

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 who are
16 years of age or over, as requested by the office processing the application. Please use a pen, and write neatly in English using BLOCK LETTERS.
Tick where applicable 3
If you need more space for any answers, give details at Part T –
Additional information

Integrity of application
The 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.

80

Part A – Applicant details
1

Important information about privacy
Your personal information is protected by law, including the
Privacy Act 1988. Important information about the collection, use and disclosure (to other agencies and third parties, including overseas entities) of your personal information, including sensitive information, is contained in form 1442i Privacy notice.
Form 1442i is available from the department’s website www.border.gov.au/allforms/ or offices of the department.
You should ensure that you read and understand form 1442i before completing this form.

Please provide your details as they appear in your official documents.
For example, passport, identity document, travel document, birth certificate. Note: If you have one name only, please write it in the ‘Family name’ field. Family name

Zhang
All given names

Xurui
Sex

Female

Male
Day

Month

Year

Day, month and year
MUST be provided

Date of birth
Suburb of birth

Xiang Cheng

Town/City of birth Xiang Yang
State/Province/Region

Hubei
Country

2

China

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)

420602199604101043

3

Are you of Russian descent?
No
Yes

© COMMONWEALTH OF AUSTRALIA, 2015

In English, provide your patronymic name

80 (Design date 10/15) - Page 1

4

Part B – Passport / Travel document details Have you been known by any other name(s)? Include:





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

No
Yes

9

Do you have a current passport or travel document?
No

Go to Question 13

Yes Give details
Passport/travel document number

Give details in English

Type of name

E52555039

Family name

Country of passport/travel document

CHINA
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

5

No

Have you ever had a different date of birth to the one shown at
Question 1?

Give original issue date

No
Yes

Day

Day

Year

Yes

Month

Year

Different date of birth

Day

Month

Year

Date of expiry

Do you currently have citizenship from any country?

Nationality

No, I am stateless

6

Month

Place of issue/issuing authority

Give details

CHINESE

Embassy of P. R. China In Australia

Yes

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

How did you gain this citizenship (eg. birth, descent, naturalisation)? Same as Question 1
Given names

Birth
Day

Month

Year

Same As Question 1

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

From

Year

Day

Month

Year

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 10/15) - Page 2

© COMMONWEALTH OF AUSTRALIA, 2015

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
Passport/travel document number

Yes Give as much information as possible
Passport/travel document number

Country of passport/travel document

Country of passport/travel document

Day

Month

Day

Year

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
QUESTION 1’)
Family name

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

Given names

Given names

11 Have you ever had any previous passports or travel documents
(including expired, lost or stolen documents)?
No

Go to Part C

Yes

12 What happened to this document (Tick one only) Expired Lost/stolen Other Give details

Part C – Identity documents
14 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

Type of identification document Country of issue

Identification number shown (if applicable)

Chinese ID

China

42060219960410

Passport

Australia

E52555039

© COMMONWEALTH OF AUSTRALIA, 2015

80 (Design date 10/15) - 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 include migration agent email addresses.
No
Yes

No
Yes

Provide all telephone numbers
Country code

Provide all of your email addresses

Area code

Number

Work

) (

)

Home

(

) (

)

Mobile/cell

XuruiZhang1996@gmail.com

(

0449235858

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
Month

Year

Date to
Month

Full address (house number, street name, suburb, town/city, postcode)

Country

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

Day

Month

80 (Design date 10/15) - Page 4

Date to
Year

Day

Month

Reason for visit
Year

© COMMONWEALTH OF AUSTRALIA, 2015

Country

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
Month

Year

Date to
Month

Year

CURRENT

Name of business/company
(no abbreviations)

Lucky way

Type of business
(eg. government department, bakery)

Take away cafe

Your occupation and duties
OR
If unemployed/retired/never worked, provide details of how you occupied your time and financially supported yourself

casual

© COMMONWEALTH OF AUSTRALIA, 2015

Full address of business/company
(Building number, street name, suburb, town/city, state/province)
(no Post Office box)

69-71 Grote Street Adelaide

Country

Australia

80 (Design date 10/15) - 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
Month

Year

Date to
Month

Year

Full name of institution
(no abbreviations)

Full name of course or description of research/
Thesis and supervisor details (no abbreviations)

Course status
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 10/15) - Page 6

© COMMONWEALTH OF AUSTRALIA, 2015

Campus/address of institution

Country

Part H – Proposed travel or further stay details 21 Are you currently in Australia?
No
Go to Question 25

Yes

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

After i met Chun i fell in love with him and wanna have a family with him to spend rest my life with him no matter where we are.
I have lodged partner visa 820/801 on 31/12/2015

23 Do you have any proposed or booked travel dates for your journey to
Australia?

26 List the towns/cities you will visit during your further stay in Australia
Adelaide

No
Yes

Give details of proposed arrival in Australia
Day

Month

27 Give details of your arrival in Australia

Year

Day

Arrival date

Month

Year

Arrival date

Flight number or vessel details (if known)

City of arrival
City of arrival

Adelaide

28 Are you applying for a temporary visa?

Give details of countries you will visit on your way to Australia
(write ‘N/A’ if not applicable)

No

Go to Part I

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

Departure date

City of departure
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, 2015

80 (Design date 10/15) - Page 7

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

Go to Question 33

Located in Australia

Located outside Australia
31 Do you know any details of the places you will stay during your time in
Australia (eg. hotel, friends, relatives)?
No

Go to Part J

33 Do you have any other addresses in Australia that have not been declared at Question 17?
No

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 street name)

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)

Suburb and town/city
Suburb and town/city
State or territory
State or territory



Postcode

Office hours

Office hours

)

(Area code

)

Mobile/cell
When and in what circumstances did you reside, or stay, at this address? Mobile/cell

32 Will you stay at any other address?
No

Postcode

Telephone numbers

Telephone numbers
(Area code



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 10/15) - Page 8

© COMMONWEALTH OF AUSTRALIA, 2015

Part J – Australian visa history
34 Are you currently in Australia?
No
Yes

Give details of current visa

Type of visa you hold
(eg. visitor, business)

Student Visa

Reason for journey

Study

Name used on entry

XURUI ZHANG

Place of visa issue

Arrival date
Day

Month

Year

ADELAIDE

35 Have you been to Australia before?
No
Yes

Give details of previous visas

Type of visa you held
(eg. visitor, business)

Reason for journey

Name used on entry

Part K – Character

Arrival date
Day

Month

Departure date
Year

Day

Month

Year

• served in a military force, police force, state sponsored/private militia or intelligence agency (including secret police)?

36 Have you, or any other person included in this application, ever:

• been charged with any offence that is currently awaiting legal action?

Place of visa issue

No

Yes

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

No

Yes

• been the subject of an arrest warrant or
Interpol notice?

• been removed, deported or excluded from any country (including Australia)?

No

Yes

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

• 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

If you answered ‘Yes’ to any of the questions at Question 36, 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.

© COMMONWEALTH OF AUSTRALIA, 2015

80 (Design date 10/15) - Page 9

Part L – Military service
37 Have you undertaken any military service?
Military service includes:
• compulsory
• conscription
• military training

• voluntary
• professional.

No
Yes

Give details in chronological order
Date from

Day

Month

Date to
Year

Day

Month

Country of service
Year

Part M – Employed by intelligence or security agency

Full name of Unit/
Battalion/Brigade

Rank

Duties

Country of deployment Part O – Deportations
40 Have you ever been excluded, asked to leave, deported or removed from

38 Are you currently, or have you been employed as an intelligence

any country?

officer or an agent of an intelligence or security agency?

No

No

Yes

Yes

Give details of organisation, role and dates you served

Part P – Citizenship refusals

Part N – Visa refusals

41 Have you ever been refused, renounced or rescinded citizenship of any country? 39 Have you ever been refused a visa to any country?

No

No
Yes

Give details of dates, countries and circumstances

Give dates of refusal, countries and circumstances of refusal 80 (Design date 10/15) - Page 10

Yes

© COMMONWEALTH OF AUSTRALIA, 2015

Give dates of refusal, countries and circumstances of refusal 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)
Relationship to you

Husband

Town/City

Given names
(include patronymic name)

Family name

Li

Chun ho
Place of birth
State/Province/Region

Guangdong

Chunho

Sex
M/F

F

Date of birth
Day

Month

Year

Chinese commercial codes
(If not applicable, write ‘N/A’)

13-Oct-1994
Country of current residence
Migrating with you?
(If not living, write ‘DECEASED’)

Citizenship(s) and year granted

Country

China

Any other names
(eg. maiden or tribal name)

July 2015

Australia

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
Relationship to you

Town/City

Family name

Place of birth
State/Province/Region

Given names
(include patronymic name)

Any other names
(eg. maiden or tribal name)

Sex
M/F

Date of birth
Day

Year

Chinese commercial codes
(If not applicable, write ‘N/A’)

Country of current residence
Migrating with you?
(If not living, write ‘DECEASED’)

Citizenship(s) and year granted

Country

Month

No

Yes

Child 2
Relationship to you

Town/City

Family name

Place of birth
State/Province/Region

Given names
(include patronymic name)

Country

Any other names
(eg. maiden or tribal name)

Citizenship(s) and year granted

Sex
M/F

Date of birth
Day

Month

Year

Chinese commercial codes
(If not applicable, write ‘N/A’)

Country of current residence
Migrating with you?
(If not living, write ‘DECEASED’)
No

© COMMONWEALTH OF AUSTRALIA, 2015

Yes

80 (Design date 10/15) - Page 11

Child 3
Relationship to you

Town/City

Family name

Place of birth
State/Province/Region

Given names
(include patronymic name)

Any other names
(eg. maiden or tribal name)

Sex
M/F

Date of birth
Day

Year

Chinese commercial codes
(If not applicable, write ‘N/A’)

Country of current residence
Migrating with you?
(If not living, write ‘DECEASED’)

Citizenship(s) and year granted

Country

Month

No

Yes

Child 4
Relationship to you

Town/City

Family name

Place of birth
State/Province/Region

Given names
(include patronymic name)

Any other names
(eg. maiden or tribal name)

Sex
M/F

Date of birth
Day

Year

Chinese commercial codes
(If not applicable, write ‘N/A’)

Country of current residence
Migrating with you?
(If not living, write ‘DECEASED’)

Citizenship(s) and year granted

Country

Month

No

Yes

Child 5
Relationship to you

Town/City

Family name

Place of birth
State/Province/Region

Given names
(include patronymic name)

Any other names
(eg. maiden or tribal name)

Sex
M/F

Date of birth
Day

Year

Country of current residence
Migrating with you?
(If not living, write ‘DECEASED’)

Citizenship(s) and year granted

Country

Month

Chinese commercial codes
(If not applicable, write ‘N/A’)

No

Yes

Child 6
Relationship to you

Town/City

Family name

Place of birth
State/Province/Region

Given names
(include patronymic name)

Country

Any other names
(eg. maiden or tribal name)

Citizenship(s) and year granted

Sex
M/F

Date of birth
Day

Month

Year

Chinese commercial codes
(If not applicable, write ‘N/A’)

Country of current residence
Migrating with you?
(If not living, write ‘DECEASED’)
No

If more than 6 children, give details at Part T – Additional information

80 (Design date 10/15) - Page 12

© COMMONWEALTH OF AUSTRALIA, 2015

Yes

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
Relationship to you

Father

Given names
(include patronymic name)

Family name

Zhang
Place of birth
State/Province/Region

Town/City

XiangChen

Hongwei

Xiangyang

N/A

Sex
M/F

M

Date of birth
Day

Month

Year

Chinese commercial codes
(If not applicable, write ‘N/A’)

N/A

09-Oct-1972

Country of current residence
Migrating with you?
(If not living, write ‘DECEASED’)

Citizenship(s) and year granted

Country

China

Any other names
(eg. maiden or tribal name)

Chinese Citizen(1972)

No

China

Yes

Parent 2
Relationship to you

Mother

Given names
(include patronymic name)

Family name

Xu

Town/City

XiangChen

Xianglin
Place of birth
State/Province/Region

Xiangyang

N/S

Sex
M/F

F

Date of birth
Day

Month

Year

06-Oct-1975

Chinese commercial codes
(If not applicable, write ‘N/A’)

N/A

Country of current residence
Migrating with you?
(If not living, write ‘DECEASED’)

Citizenship(s) and year granted

Country

China

Any other names
(eg. maiden or tribal name)

Chinese Citizen(1975)

No

China

Yes

Parent 3
Relationship to you

Town/City

Family name

Place of birth
State/Province/Region

Given names
(include patronymic name)

Any other names
(eg. maiden or tribal name)

Sex
M/F

Date of birth
Day

Year

Chinese commercial codes
(If not applicable, write ‘N/A’)

Country of current residence
Migrating with you?
(If not living, write ‘DECEASED’)

Citizenship(s) and year granted

Country

Month

No

Yes

Parent 4
Relationship to you

Town/City

Family name

Place of birth
State/Province/Region

Given names
(include patronymic name)

Country

Any other names
(eg. maiden or tribal name)

Citizenship(s) and year granted

Sex
M/F

Date of birth
Day

Month

Year

Chinese commercial codes
(If not applicable, write ‘N/A’)

Country of current residence
Migrating with you?
(If not living, write ‘DECEASED’)
No

Yes

If more than 4 parents, give details at Part T – Additional information
© COMMONWEALTH OF AUSTRALIA, 2015

80 (Design date 10/15) - Page 13

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
Relationship to you

Brother

Given names
(include patronymic name)

Family name

Zhang

Town/City

Xiangchen

Xufeng

Place of birth
State/Province/Region

Xiangyang

N/A

Sex
M/F

M

Date of birth
Day

Month

Year

04-Jan-2003

Chinese commercial codes
(If not applicable, write ‘N/A’)

N/A

Country of current residence

Citizenship(s) and year granted

Country

China

Any other names
(eg. maiden or tribal name)

Chinese Citizen (2003)

Migrating with you?
No

China

Yes

Sibling 2
Relationship to you

Town/City

Family name

Place of birth
State/Province/Region

Given names
(include patronymic name)

Any other names
(eg. maiden or tribal name)

Sex
M/F

Date of birth
Day

Year

Chinese commercial codes
(If not applicable, write ‘N/A’)

Country of current residence

Citizenship(s) and year granted

Country

Month

Migrating with you?
No

Yes

Sibling 3
Relationship to you

Town/City

Family name

Place of birth
State/Province/Region

Given names
(include patronymic name)

Any other names
(eg. maiden or tribal name)

Sex
M/F

Date of birth
Day

Year

Chinese commercial codes
(If not applicable, write ‘N/A’)

Country of current residence

Citizenship(s) and year granted

Country

Month

Migrating with you?
No

Yes

Sibling 4
Relationship to you

Town/City

Family name

Place of birth
State/Province/Region

Given names
(include patronymic name)

Country

Any other names
(eg. maiden or tribal name)

Citizenship(s) and year granted

Sex
M/F

Date of birth
Day

Month

Year

Chinese commercial codes
(If not applicable, write ‘N/A’)

Country of current residence

Migrating with you?
No

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© COMMONWEALTH OF AUSTRALIA, 2015

Yes

Sibling 5
Relationship to you

Town/City

Family name

Place of birth
State/Province/Region

Given names
(include patronymic name)

Any other names
(eg. maiden or tribal name)

Sex
M/F

Date of birth
Day

Year

Chinese commercial codes
(If not applicable, write ‘N/A’)

Country of current residence

Citizenship(s) and year granted

Country

Month

Migrating with you?
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
Relationship to you

Town/City

Family name

Place of birth
State/Province/Region

Given names
(include patronymic name)

Any other names
(eg. maiden or tribal name)

Sex
M/F

Date of birth
Day

Year

Country of current residence

Citizenship(s) and year granted

Country

Month

Chinese commercial codes
(If not applicable, write ‘N/A’)

Family member 2
Relationship to you

Town/City

Family name

Place of birth
State/Province/Region

Given names
(include patronymic name)

Country

Any other names
(eg. maiden or tribal name)

Citizenship(s) and year granted

Sex
M/F

Date of birth
Day

Month

Year

Chinese commercial codes
(If not applicable, write ‘N/A’)

Country of current residence

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

© COMMONWEALTH OF AUSTRALIA, 2015

80 (Design date 10/15) - Page 15

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 members and acquaintances in Australia.
No

Go to Part R

Yes

Provide as much information about one of your personal contacts as possible
Family name

No

Go to Part R

Yes Give details
Family name

LI
Given names

CHINWEI

Li
Given names

Female
Sex
Male
Relationship to you (eg. partner, sister, aunt, friend)

Chun ho

MOTHER IN THE LAW

Female
Sex
Male
Relationship to you (eg. partner, sister, aunt, friend)

Day

Month

Year

Date of birth

Partner
Day

Month

Town/City of birth YUEYANG

Year

Date of birth

State/Province/Region

HUNAN

Town/City of birth Guangdong
State/Province/Region

Country
Nationality

Guangdong
Country

China

Nationality

Chinese

CHINA
CHINESE

Your personal contact’s current residential address
Note: A post office box is not acceptable.
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)

11 HAWKESBURY AVE

11 HAWKESBURY AVE
Suburb and town/city

KILBURN
Suburb and town/city

State or territory SA

KILBURN

Postcode 5084

Telephone numbers

State or territory SA

Postcode 5084

Office hours

(Area code

Mobile/cell

0410746734

)

Office hours

(Area code

Mobile/cell



Telephone numbers

0420399583

)

Email address CoffeeChen888@gmail.com
Give details of all other contacts at Part T – Additional information

Email address F_3426@HOTMAIL.COM

80 (Design date 10/15) - Page 16



© COMMONWEALTH OF AUSTRALIA, 2015

Part R – Sponsoring employer details

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?
No

Part S – Declaration
53 I declare that:

Go to Part S

• 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.
• I have read the information contained in form 1442i Privacy notice.
• I understand the department may collect, use and disclose my personal information (including biometric information and other sensitive information) as outlined in form 1442i Privacy notice.

Yes Give details
Organisation/Business name

Organisation/Business description

Organisation/Business commercial address (including building number and street name)

Signature of applicant 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)

© COMMONWEALTH OF AUSTRALIA, 2015

80 (Design date 10/15) - Page 17

Part T – Additional information
54

Question number Additional information

If you do not have enough space to give all the necessary information, attach a separate statement to this form with further details
80 (Design date 10/15) - Page 18

© COMMONWEALTH OF AUSTRALIA, 2015

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