Personal Particulars For Assessment Including Character Assessment

Form
Personal particulars for assessment

including character assessment 80
Important Please read this information carefully before you Please use a pen, and write neatly in English using BLOCK LETTERS.
complete this form. Once you have completed this form we 3
strongly advise that you keep a copy for your records. Tick where applicable
This form is to be completed in English by applicants for visas

I am applying for a visa to travel to Australia as a: migrant
for Australia who are 16 years of age or over, as requested by the
office processing the application. temporary resident
visitor
Integrity of application student
The Department of Immigration and Citizenship (the
department) is committed to maintaining the integrity of the refugee/ humanitarian entrant
visa and citizenship programs. Please be aware that if you OR
provide us with fraudulent documents or claims, this may I am applying in Australia for: a further temporary stay or visit
result in processing delays and possibly your application being
refused. permanent residence
protection
About the information you give
The Department of Immigration and Citizenship (the Part A Your details
department) has authority under the Migration Act 1958 and
the Australian Citizenship Act 2007 and other legislation it 1 Write your name and birth details as shown on your current
administers, to collect personal information to carry out its passport, birth certificate, family book or travel document
functions, including administration of applications for visas for
entry and/or stay in Australia or for citizenship. The information Passport
provided will be used for assessing your eligibility for a visa to Other Type of document
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
Note: If your passport/travel document only shows one name,
compliance with the Migration Act.
write that name in the Family name box.
The information provided might also be disclosed to agencies
who are authorised to receive information relating to adoption, Family name
border control, business skills, citizenship, education, health
assessment, health insurance, health services, law enforcement, All given
payment of pensions and benefits, taxation, superannuation, names
review of decisions and registration of migration agents.
The information form 993i Safeguarding your personal
information, available from offices of the department, gives Sex Male Female
details of agencies to which your information might be
DAY MONTH YEAR
disclosed. Day, month and year
Date of birth MUST be provided
Place of birth
Suburb and
Town/City
State/Province/
Region
Country
Passport/travel document number
Country of passport/travel document
DAY MONTH YEAR
Date of issue
Date of expiry
Nationality
Place of issue/issuing authority
COMMONWEALTH OF AUSTRALIA, 2013 80 (Design date 07/13) - Page 1

2 Relationship status 7 Are you of Russian descent?
DAY MONTH YEAR
Married Date of marriage No

Yes In English, provide your patronymic name
Engaged Date of intended marriage
De facto Date relationship began

Separated 8 Have you ever been known by other names or spellings of your name?
Divorced Examples of the types of other names:
Widowed name at birth cultural or tribal name or
name before or after marriage clan/subclan name
Never married or
been in a de facto adoptive or foster name preferred name
relationship alias or pseudonym other spellings of names
3 Does the passport/travel document at Question 1 show your No

full name? Yes Give details in English
No What is your full name?
1. Type of name
Family name
Family name
Given names
Given names
Yes
2. Type of name
4 Did you use the passport/travel document at Question 1 Family name
to enter Australia?
No Write the number of the document you used to
enter Australia Given names
Yes
If more than 2, give details at Part J Additional details
5 Do you ever use a Chinese Commercial Code Number for your names
shown in the passport/travel document at Question 1 9 Have you ever had a different date of birth?
No No DAY MONTH YEAR
Yes Chinese Commercial Code Number (in full) Yes Different date of birth
10 Are you a citizen of the country of passport/travel document at

6 Are you of Arabic descent? Question 1?
No No
Yes In English, write the full name of your fathers father Yes How did you gain this citizenship (eg. birth, descent,
(ie. your paternal grandfather) naturalisation)?
DAY MONTH YEAR
Date you gained this citizenship
80 (Design date 07/13) - Page 2 COMMONWEALTH OF AUSTRALIA, 2013

11 Do you currently have, or have you ever had, other passports/travel 12 Are you currently, or have you ever been, a citizen of any other
documents not already shown at Question 1? country not already shown at Question 1 or Question 11?
No No
Yes Give details as they appear on the other passports/travel Yes Give details
documents (If more than one, give details at Part J
Additional details) 1. Country
Note: If the passport/travel document only shows one name, write How did you gain this citizenship (eg. birth, descent,
that name in the Family name box. naturalisation)?
Family name
When did you have this citizenship?
DAY MONTH YEAR
All given
names From
To (If you still have the citizenship,
write Current)
Passport/travel document number
2. Country
Country of passport/travel document How did you gain this citizenship (eg. birth, descent,
naturalisation)?
DAY MONTH YEAR
Date of issue When did you have this citizenship?

DAY MONTH YEAR
Date of expiry From

To (If you still have the citizenship,
Nationality write Current)
Place of issue/issuing authority If more than 2, give details at Part J Additional details
13 Have you ever renounced any citizenship you have previously held?
Are you, or have you ever been, a citizen of the country of passport/ No
travel document shown above? Yes Give details
No Country
Yes How did you gain this citizenship (eg. birth, descent,
Reason
naturalisation)?
DAY MONTH YEAR

When did you have this citizenship? Date of renouncement
DAY MONTH YEAR
From
14 Do you currently have permanent residence rights in any country
To (If you still have the not already shown at Question 1, Question 11 or Question 12?
citizenship, write Current)
No
Yes Give details
1. Country
2. Country

15 Have you ever been refused citizenship of any country?
No
Yes Give details
1. Country
Reason for refusal
DAY MONTH YEAR
Date
2. Country
Reason for refusal
DAY MONTH YEAR
Date
16 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 Name shown on document
(if applicable)
17 Your current residential address (this is the place where you 18 Do you have an e-mail address?
currently live) Note: Do not provide the e-mail address of a migration agent.
Note: A post office box or mailbox address is not acceptable as a No
residential address.
Yes Please provide all of your e-mail addresses
Unit/Apartment number
Address (including street number and name)
Suburb and 19 Your current contact numbers (include country code if outside Australia)
Town/City COUNTRY CODE AREA CODE NUMBER
State/Province/ Work ( ) ( )
Region
Country Home ( ) ( )
Postal code Mobile/cell
Fax ( ) ( )
Other contact numbers you have

( ) ( )
( ) ( )

20 Address in Australia where you can be contacted or will be staying 2. Family name
Note: A post office box or mailbox address is not acceptable.
Given names
Sex Male Female

POSTCODE DAY MONTH YEAR
Date of birth
21 Contact telephone numbers in Australia (if known) Place of birth
AREA CODE NUMBER Suburb and
Work ( ) Town/City
State/Province/
Home ( ) Region
Country
Mobile/cell
Other contact numbers Nationality
( ) Your personal contacts current residential address
Note: A post office box or mailbox address is not acceptable
( )
as a residential address.
22 Do you have personal contacts in Australia (including business
contacts/sponsor)? Address (including street number and name)
Note: Do not provide the contact details of a migration agent.
No
Yes Give details
1. Family name Suburb and
Town/City
Given names State/Province/
Region
Country
Sex Male Female
DAY MONTH YEAR Postal code
Date of birth Telephone
AREA CODE NUMBER
Place of birth number ( )
Suburb and Relationship to you (eg. partner, sister, aunt, friend,

Town/City
business contact/sponsor)
State/Province/
Region
Country
Nationality
Your personal contacts current residential address
Note: A post office box or mailbox address is not acceptable
as a residential address.
Address (including street number and name)
Suburb and
Town/City
State/Province/
Region
Country
Postal code
AREA CODE NUMBER
Telephone
number ( )
Relationship to you (eg. partner, sister, aunt, friend,

business contact/sponsor)

Part B Your partners details
30 Is your partner of Arabic descent?
23 Do you currently have a partner? No
Note: If you are widowed, you must answer Yes and give details for
your deceased partner. Yes In English, write the full name of your partners
fathers father (ie. paternal grandfather)
No Go to Part C
Yes
24 Your partners full name

31 Is your partner of Russian descent?
Family name No
All given Yes In English, provide your partners patronymic name
names
32 Is your partner currently, or have they ever been, known by other

names or spellings of their name?
25 Sex Male Female
Examples of the types of other names:
DAY MONTH YEAR name at birth cultural or tribal name or
Day, month and year
26 Date of birth MUST be provided name before or after marriage clan/subclan name
Date of death adoptive or foster name preferred name
(if deceased) alias or pseudonym other spellings of names
27 Your partners place of birth No
Suburb and Yes Give details in English

Town/City
1. Type of name
State/Province/
Region Family name
Country
Given names
28 Is your partner currently, or have they ever been, a citizen of any
country?
No
Yes Give details
2. Type of name
1. Country Family name
When did your partner have this citizenship?
DAY MONTH YEAR
From Given names
To (If they still have the

2. Country If more than 2, give details at Part J Additional details

When did your partner have this citizenship?
DAY MONTH YEAR 33 Country where your partner lives now
From If in Australia, write the full address, if deceased, write DECEASED
To (If they still have the
29 Does your partner ever use a Chinese Commercial Code Number for POSTCODE
names shown at Question 24?

No
Yes Chinese Commercial Code Number (in full)

34 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
Type of identification document Country of issue Identification number shown Name shown on document
(if applicable)
Part C Travel to Australia

35 Are you planning to travel to Australia with any other person(s) OR 37 Details of proposed arrival in Australia
if you are in Australia did you travel with any other person(s)? DAY MONTH YEAR
No Arrival date
Yes Give details Flight number or vessel details (if known)
1. Family name
City of arrival
Given names
38 Are you applying for a temporary visa?
No
Yes Details of proposed final departure from Australia
DAY MONTH YEAR
DAY MONTH YEAR
Date of birth
Departure date
Country of
birth Flight number or vessel details (if known)
Nationality
Relationship to you (eg. partner, sister, friend, business contact) City of

departure
39 What is the main reason for going to Australia?

2. Family name Include details of any dates that are of special significance to
your time in Australia.
Given names
DAY MONTH YEAR
Date of birth
Country of
birth
Nationality
Relationship to you (eg. partner, sister, friend, business contact)

Go to Part E
36 Are you currently in Australia?
No
Yes Go to Part D

Part D Current visa details
NOTE: Only complete this Part if you are currently in Australia
40 Do you currently hold an Australian visa?

No Go to Part E
Yes
41 Visa details
Type of visa
DAY MONTH YEAR
Date of issue
Place of issue
42 Details of your arrival in Australia

DAY MONTH YEAR
Arrival date
City of arrival
43 Final date you must leave Australia DAY MONTH YEAR
on this visa
Part E Other information

44 Have you travelled to Australia before?
No
Yes Give details in chronological order
(If insufficient space, give details at Part J Additional details)
Date from Date to Type of visa (eg. visitor, Place where

student, business) visa was issued Your names shown on visa Reason for visit
DAY MONTH YEAR DAY MONTH YEAR
45 Have you travelled to any country other than Australia, including any visits back to your
country of citizenship during the past 10 years (including short stays)?
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 (both month and year are required).
No
Date from Date to

Country or countries Reason for visit

46 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 month/year. If you are unable
to provide an address for any period of time please provide an explanation.
Note: If you are applying for a refugee/humanitarian visa you must provide all addresses
for the last 30 years (both month and year are required with no gaps).
Date from Date to

Country Full address (number, street name, suburb, state/province, region)
MONTH YEAR MONTH YEAR
47 Give details of all employment including periods of unemployment.

Note: If you are unable to provide details for a period, please provide an
explanation. (If insufficient space, give details at Part J Additional details)
For current or previous periods of unemployment please advise how you
occupied your time and how you supported yourself. Month and year are both
required. If retired, please provide activities. Time gaps are unacceptable.
Date from Date to Name and address of employer/business. Type of business/ Your position/title/duties/how you
Do not use abbreviations. other activities spent your time if unemployed

48 Have you had any military service?
No
Date from Date to Full name of Unit/ Country of
Country of service Battalion/Brigade Rank Duties deployment
49 List all education and qualifications undertaken, including courses completed,

withdrawn or continuing. (If insufficient space, give details at Part J Additional details)
Give details in chronological order.
Date from Date to Country where Name and address of institution. Course of study.
course undertaken Do not use abbreviations. Do not use abbreviations. Course status
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)?
No
Yes Give details
Full name of your supervisor

Family name
Given names

Part F About your parents h. Does this parent ever use a Chinese Commercial Code Number?
Note: You must give details for any person (living or deceased) who
No
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, Yes Chinese Commercial Code Number (in full)
adoptive parents, surrogate parents, step-parents, foster parents, and/
or guardians.
Provide details of one parent at Question 51 and the other parent at i. Is this parent of Arabic descent?
Question 52. If more than 2, give details at Part J Additional details. No
Yes In English, write the full name of this parents father
51 Parent
a. Relationship to you (eg. natural parent, step-parent etc)
b. This parents full name j. Is this parent of Russian descent?

Family name No
Yes In English, provide this parents patronymic name
All given names including, if applicable, patronymic name
(in English), clan and sub-clan names, and middle names
k. Is this parent currently, or have they ever been, known by other names
or spellings of their name?
name at birth cultural or tribal name or
c. Sex Male Female name before or after marriage clan/subclan name
DAY MONTH YEAR adoptive or foster name preferred name
d. Date of birth alias or pseudonym other spellings of names
e. Date of death (if deceased) No Yes Give details in English

f. This parents place of birth
1. Type of name
Suburb and
Town/City Family name
State/Province/
Region
Given names
Country
g. Is this parent currently, or have they ever been, a citizen of any

country?
No 2. Type of name
Yes Give details Family name
1. Country
When did this parent have this citizenship? Given names
DAY MONTH YEAR
From
To (If they still have the citizenship,
write Current)
l. Country where this parent lives now
If in Australia, write the full address, if not living, write DECEASED
2. Country
When did this parent have this citizenship?
DAY MONTH YEAR
From
To (If they still have the citizenship, POSTCODE
write Current)

52 Parent h. Does this parent ever use a Chinese Commercial Code Number?
a. Relationship to you (eg. natural parent, step-parent etc) No
b. This parents full name
Family name
i. Is this parent of Arabic descent?
All given names including, if applicable, patronymic name No

(in English), clan and sub-clan names, and middle names Yes In English, write the full name of this parents father
j. Is this parent of Russian descent?

c. Sex Male Female No
DAY MONTH YEAR
Yes In English, provide this parents patronymic name
d. Date of birth
e. Date of death (if deceased)

k. Is this parent currently, or have they ever been, known by other names
f. This parents place of birth or spellings of their name?
Suburb and
Town/City Examples of the types of other names:
name at birth cultural or tribal name or
State/Province/
Region name before or after marriage clan/subclan name
adoptive or foster name preferred name
Country
alias or pseudonym other spellings of names
g. Is this parent currently, or have they ever been, a citizen of any
country? No Yes Give details in English
No
1. Type of name
Yes Give details
Family name
1. Country
When did this parent have this citizenship? Given names
DAY MONTH YEAR
From
write Current)
2. Type of name
2. Country
Family name
When did this parent have this citizenship?
DAY MONTH YEAR
From Given names

write Current)
l. Country where this parent lives now

If in Australia, write the full address, if not living, write DECEASED
POSTCODE

Part G About your brothers and sisters i. Is this person of Arabic descent?
Note: You must give details for any person (living or deceased) who No
is or was your brother or sister. This should include, but is not limited
to, natural brothers and sisters, adoptive brothers and sisters, step- Yes In English, write the full name of this persons fathers
brothers and sisters. father (ie. paternal grandfather)
Provide details of one brother or sister at Question 53 and the others

at Questions 5456. If more than 4, give details at Part J Additional
details.
j. Is this person of Russian descent?
53 Brother or sister No
a. Relationship to you (eg. brother, sister, step-brother, step-sister) Yes In English, provide their patronymic name
b. Family name k. Is this person currently, or have they ever been, known by other names
or spellings of their name?
All given names including, if applicable, patronymic name Examples of the types of other names:
(in English), clan and sub-clan names, and middle names name at birth cultural or tribal name or
adoptive or foster name preferred name
alias or pseudonym other spellings of names
c. Sex Male Female No

DAY MONTH YEAR Yes Give details in English
d. Date of birth
1. Type of name
e. Date of death (if deceased) Family name
f. Place of birth
Suburb and Given names
Town/City
State/Province/
Region
Country
2. Type of name
g. Is this person currently, or have they ever been, a citizen of any
country? Family name
No
Yes Give details Given names
1. Country
When did this person have this citizenship?
DAY MONTH YEAR
l. Country where this person lives now
From If in Australia, write the full address, if not living, write DECEASED
write Current)
2. Country
When did this person have this citizenship? POSTCODE
DAY MONTH YEAR
From
write Current)
h. Does this person ever use a Chinese Commercial Code Number?

No

54 Brother or sister i. Is this person of Arabic descent?
a. Relationship to you (eg. brother, sister, step-brother, step-sister) No
Yes In English, write the full name of this persons fathers
father (ie. paternal grandfather)
b. Family name

(in English), clan and sub-clan names, and middle names j. Is this person of Russian descent?
No
Yes In English, provide their patronymic name
c. Sex Male Female k. Is this person currently, or have they ever been, known by other names
DAY MONTH YEAR or spellings of their name?
d. Date of birth
e. Date of death (if deceased) name at birth cultural or tribal name or
f. Place of birth preferred name
adoptive or foster name
Suburb and other spellings of names
Town/City alias or pseudonym
State/Province/ No
Region
Yes Give details in English
Country
1. Type of name
No
1. Country
DAY MONTH YEAR
From 2. Type of name

To (If they still have the citizenship, Family name
write Current)
2. Country Given names

DAY MONTH YEAR
From
To (If they still have the citizenship, l. Country where this person lives now
write Current) If in Australia, write the full address, if not living, write DECEASED

No
POSTCODE

b. Family name

No
d. Date of birth
State/Province/ No
Region
Country
1. Type of name
No
1. Country
DAY MONTH YEAR

write Current)

DAY MONTH YEAR
From

No
POSTCODE

b. Family name

No
d. Date of birth
State/Province/ No
Region
Country
1. Type of name
No
1. Country
DAY MONTH YEAR

write Current)

DAY MONTH YEAR
From

No
POSTCODE

Part H Character details
57 Have you, or any other person included in this If you answered Yes to any of the questions at Question 57, you
application, ever: must state who it applies to and give ALL relevant details. If the matter
been convicted of a crime or offence in any relates to a criminal conviction, please give the nature of the offence,
country (including any conviction which is full details of sentence, court details and dates of any period of
now removed from official records)? No Yes imprisonment or other detention.
been charged with any offence or have If insufficient space, give details at Part J Additional details
proceedings against you overseas or in
Australia No Yes
been acquitted of any criminal offence or
other offence on the grounds of mental
illness, insanity or unsoundness of mind? No Yes
been confined in a prison or psychiatric
institution by order of a court made in
connection with criminal proceedings
overseas or in Australia? No Yes
been removed or deported from any country
(including Australia)? No Yes 58 Are you currently, or have you been employed as an intelligence
officer or an agent of an intelligence or security agency?
left any country to avoid being removed or
deported (including Australia)? No Yes No
been refused a visa for Australia or any Yes Give details of organisation, role and dates you served
other country? No Yes
been excluded from or asked to leave any

country (including Australia)? No Yes
committed, or been involved in the
commission of war crimes or crimes against
humanity or human rights? No Yes
been involved in any activities that would
represent a risk to Australian national 59 Have you ever had a visa cancelled by, been refused entry to, or
security? No Yes been deported from, any country?
had any outstanding debts to the Australian No

Government or any public authority in Yes Give details of dates, countries and circumstances.
Australia? No Yes If insufficient space, give details at Part J Additional
been involved in any activity, or been details
convicted of any offence, relating to the
illegal movement of people to any country
(including Australia)? No Yes
been associated with or involved in a
program related to the development of
weapons of mass destruction? No Yes
been associated with or received training
from an organisation engaged in violence, or
been involved in an act of violence (including Part I Declaration
war, insurgency, freedom fighting, terrorism,
protest) overseas or in Australia? No Yes WARNING: Giving false or misleading information is a serious offence.
been under a probation order, good 60 I declare that:
behaviour bond, on parole, released on the information I have supplied in or with this form is complete,
licence or subject to a periodic detention correct and up-to-date in every detail.
overseas or in Australia? No Yes I have read and understand the information supplied to me.
Signature of
applicant
DAY MONTH YEAR
Date
We strongly advise that you keep a copy of your application

and all attachments for your records.

Part J Additional details
61 Question number Additional information
If insufficient space, attach additional details

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Form

Personal particulars for assessment

This form is to be completed in English by applicants for visas

Country of passport/travel document

DAY MONTH YEAR

COMMONWEALTH OF AUSTRALIA, 2013 80 (Design date 07/13) - Page 1

Married Date of marriage No

De facto Date relationship began

3 Does the passport/travel document at Question 1 show your No

10 Are you a citizen of the country of passport/travel document at

DAY MONTH YEAR

Date you gained this citizenship

80 (Design date 07/13) - Page 2 COMMONWEALTH OF AUSTRALIA, 2013

DAY MONTH YEAR

Date of issue When did you have this citizenship?

Date of expiry From

DAY MONTH YEAR

COMMONWEALTH OF AUSTRALIA, 2013 80 (Design date 07/13) - Page 3

DAY MONTH YEAR

DAY MONTH YEAR

If more than 2, give details at Part J Additional details

Postal code Mobile/cell

Other contact numbers you have

80 (Design date 07/13) - Page 4 COMMONWEALTH OF AUSTRALIA, 2013

Sex Male Female

Place of birth number ( )

Suburb and Relationship to you (eg. partner, sister, aunt, friend,

Relationship to you (eg. partner, sister, aunt, friend,

COMMONWEALTH OF AUSTRALIA, 2013 80 (Design date 07/13) - Page 5

24 Your partners full name

32 Is your partner currently, or have they ever been, known by other

27 Your partners place of birth No

Suburb and Yes Give details in English

From Given names

To (If they still have the

2. Country If more than 2, give details at Part J Additional details

names shown at Question 24?

80 (Design date 07/13) - Page 6 COMMONWEALTH OF AUSTRALIA, 2013

Part C Travel to Australia

Yes Give details Flight number or vessel details (if known)

Relationship to you (eg. partner, sister, friend, business contact) City of

39 What is the main reason for going to Australia?

DAY MONTH YEAR

Relationship to you (eg. partner, sister, friend, business contact)

If more than 2, give details at Part J Additional details

COMMONWEALTH OF AUSTRALIA, 2013 80 (Design date 07/13) - Page 7

40 Do you currently hold an Australian visa?

42 Details of your arrival in Australia

43 Final date you must leave Australia DAY MONTH YEAR

Part E Other information

Date from Date to Type of visa (eg. visitor, Place where

Date from Date to

80 (Design date 07/13) - Page 8 COMMONWEALTH OF AUSTRALIA, 2013

Date from Date to

47 Give details of all employment including periods of unemployment.

COMMONWEALTH OF AUSTRALIA, 2013 80 (Design date 07/13) - Page 9

49 List all education and qualifications undertaken, including courses completed,

50 Have you undertaken an academic thesis, dissertation or publication (including

Full name of your supervisor

80 (Design date 07/13) - Page 10 COMMONWEALTH OF AUSTRALIA, 2013

b. This parents full name j. Is this parent of Russian descent?

e. Date of death (if deceased) No Yes Give details in English

g. Is this parent currently, or have they ever been, a citizen of any