Application for an
Offshore Humanitarian visa
Refugee and Humanitarian (Class XB) visa
The Department of Immigration and Border Protection (the
department) acknowledges that Aboriginal and Torres Strait
Islander peoples are the traditional custodians of the Australian
land.
Life in Australia – Australian values
The Australian Government encourages people to gain an
understanding of Australia, its people and their way of life,
before applying for a visa to live in Australia.
This includes understanding that the English language, as the
national language, is an important unifying element of
Australian society. Australian society is also united through
the following shared values:
• respect for the freedom and dignity of the individual;
• freedom of religion;
• commitment to the rule of law;
• Parliamentary democracy;
• equality of men and women;
• a spirit of egalitarianism that embraces mutual respect,
tolerance, fair play and compassion for those in need and
pursuit of the public good;
• equality of opportunity for individuals, regardless of their
race, religion or ethnic background.
The Life in Australia booklet provides more information on
the values that Australians share and their way of life. This
booklet is available in a wide range of languages. If you have
not already received a copy then it can be obtained from
www.border.gov.au
You must read the Life in Australia booklet before
completing this application form. If you have difficulty, or are
unable to read the booklet, you may have the content of it
explained to you, for example, by a friend or relative. This
form contains a statement, that you must sign, that confirms
you understand and will respect the values of Australian
society (as explained in the booklet) and will obey the laws
of Australia. This includes acknowledging what would be
required if you later applied for Australian citizenship.
This statement must also be signed by each person aged
18 years or over, who is included in this form.
Who should use this application?
You should use this form if you are outside Australia and wish to
apply for entry to Australia on humanitarian grounds. This class
of visa includes the following 5 subclasses:
• Refugee (subclass 200)
• In-country Special Humanitarian (subclass 201)
• Global Special Humanitarian (subclass 202)
• Emergency Rescue (subclass 203)
• Woman at Risk (subclass 204).
You should also use this form if you are applying for one of the
above visas in the Community Proposal Pilot programme.
© COMMONWEALTH OF AUSTRALIA, 2016
Form
842
About this form
Important – Please read this information carefully before you
complete your application. When you have completed your
application we recommend that you keep a copy for your
records.
Australia’s offshore humanitarian programme
There are a limited number of places available each year under
the programme. In setting the size of the programme, the
Australian Government considers:
• the views of the United Nations High Commissioner for
Refugees (UNHCR);
• the views of the Australian community; and
• Australia’s capacity to settle refugees and people in need.
Requirements for each visa subclass
Your application will be assessed against the 5 visa subclasses of
the Refugee and Humanitarian (Class XB) visa class. To be
granted a visa, you must be assessed as meeting the
requirements for one of these subclasses. These are set out in
Australia’s Migration Act and Regulations and the main
requirements for each subclass are:
Refugee (subclass 200)
• You are living outside your home country; and
• subject to persecution in your home country; and
• in need of resettlement.
The UNHCR provides advice to the Australian Government on
the need for resettlement.
In-country Special Humanitarian (subclass 201)
• You are in your home country; and
• subject to persecution.
Only a small number of places are available under this subclass.
Global Special Humanitarian (subclass 202)
• You are living outside your home country; and
• you are subject to substantial discrimination amounting to
gross violation of your human rights in your home country;
and
• have included a valid form 681 Refugee and Special
Humanitarian Proposal with your application.
Form 681 needs to be completed by an Australian citizen or
permanent resident, eligible New Zealand citizen, or community
organisation in Australia (a ‘proposer’), who is willing to support
your application.
As the government does not fund travel costs for this visa
subclass, your proposer is expected to assist you and any
dependants in meeting costs associated with travel to Australia
and initial settlement after arrival.
Emergency Rescue (subclass 203)
• You are subject to persecution in your home country; and
• there are urgent and compelling reasons for you to be
resettled in Australia.
Requests for urgent assistance under this subclass are usually
made on your behalf by the UNHCR.
842 (Design date 07/16) - Page 1
Woman at Risk (subclass 204)
• You are a woman living outside your home country; and
• subject to persecution in your home country or are registered
with the UNHCR as being ‘of concern’; and
• without the protection of a male relative; and
• in danger of victimisation, harassment or serious abuse
because you are female.
Children under 18
Children under the age of 18 who have no parents, or who have
been separated from their parents, may also be granted a visa in
one of the subclasses listed above. However, the Australian
Government must be satisfied the child’s entry to Australia is in
the best interest of the child and that the rights of the parents, if
any, are properly considered.
If any children under 18 who are members of the family unit and
included in this application are not your biological children, you
must provide information and documentation as to who their
birth parents are/were.
Community Proposal Pilot
The Community Proposal Pilot allows community organisations
within Australia to identify and support individuals and families in
humanitarian situations outside Australia, to apply for Refugee
and Humanitarian (Class XB) visas. Only Approved Proposing
Organisations (APOs) may propose people for entry into
Australia in the Community Proposal Pilot.
Information about the Community Proposal Pilot is available
from the department’s website
www.border.gov.au/refugeeandhumanitarian/documents/
comm-proposal-pilot-info-sheet.pdf
Note: Your APO must complete form 1417 Proposal for refugee
and special humanitarian entrants by Approved Proposing
Organisation. Your APO must lodge both of these forms (form
842 and form 1417) by post or courier at the department’s
Special Humanitarian Processing Centre (SHPC).
The department will share your personal information that was
collected during the processing of your application with your
APO. If a visa is granted, this information may be used by the APO
to enable delivery of settlement services and support. Your APO
may also share your personal information with other
organisations, known as Supporting Community Organisations,
so they can provide services to you to help you settle in Australia.
‘Split family’ provisions for immediate family of permanent
Protection (Class XA), permanent humanitarian
(Class XB) or Resolution of Status (Class CD) visa holders.
You should use this form if, within the last 5 years a member of
your ‘immediate family’ was granted either a:
• permanent Protection visa (subclass 866); or
• permanent humanitarian visa (subclasses 200, 201, 202, 203
or 204); or
• Resolution of Status (Class CD) visa (subclass 851).
Note: Your proposer must not have been an illegal maritime
arrival who arrived on or after 13 August 2012.
Note: Under the ‘split family’ provisions, ‘Immediate family’
means you are the spouse, de facto partner (including
same-sex partner), dependent child or in certain
circumstances a parent of the person in Australia who is
proposing your entry (that is, your proposer has completed
form 681).
Note: You can only apply as a parent under these ‘split family’
provisions if your child in Australia is under 18 years of age.
842 (Design date 07/16) - Page 2 © COMMONWEALTH OF AUSTRALIA, 2016
To be eligible for the grant of a humanitarian visa under the ‘split
family’ provisions for immediate family:
• you must apply within 5 years of the permanent Protection,
permanent humanitarian or Resolution of Status visa being
granted to your proposer;
• your proposer must complete a form 681 Refugee and
Special Humanitarian Proposal (available from offices of the
department in Australia or the immigration website) for you to
submit together with your own visa application;
• your proposer must have declared you to the department as an
immediate family member before the grant of their own visa.
Partner
‘Partner’ means your spouse or de facto partner (including
same-sex partners).
Residential address
You must advise the department where you intend to live while
your application is being dealt with, or if you change your
residential address after your application has been lodged.
Failure to give a residential address will result in your application
being invalid. A post office box address will not be accepted as
your residential address.
Your application
You should answer the questions in this form truthfully and fully
and attach any supporting documents. Forms that are incomplete
could delay a decision being made on your application, or your
application could be refused.
Not all applicants are interviewed and a decision may be taken on
the information provided in your application only. You need to
make sure you include all details about your situation in your
application.
If you need more space than is provided in this form for any of
your answers, attach a separate page, clearly marking the
question number the page relates to. Additional pages must be
signed and dated by each person aged 18 years or over included
in this application.
Who should be included in this application?
You should include in this form ALL members of your family unit.
Your family unit includes your spouse, de facto partner (including
same-sex partner), dependent children outside Australia and
other dependent relatives who usually live with you (eg. a
dependent parent). ‘Dependent’ means wholly or substantially
dependent on you or your partner for financial, psychological or
physical support.
Details of dependent family members NOT included in your visa
application should be included at Question 11. If you fail to
declare immediate family members in your application, they may
not be able to access the ‘split family’ provisions for immediate
family members (referred to above) if they apply for a visa at a
later time.
Non-dependent family members (eg. married children or
children over 18 who are independent) should complete their
own form 842 if they wish to be considered for entry to Australia
on humanitarian grounds.
Integrity of application
The department is committed to maintaining the integrity of the
visa and citizenship programmes. Please be aware that if you
provide us with fraudulent documents or claims, this may result
in processing delays or your application being refused.
What documents should you attach to this application?
Eight (8) passport-sized photographs of each person included in
the application, that have the name of the person written on the
back.
Supporting documents
The documents you must provide are requested throughout this
form. There is also a document checklist in Part Q of this form
and you should carefully check you have provided all the listed
documents.
You should also provide all documents necessary to support
your humanitarian claims.
Copies of documents must be certified as true copies of the
original by a Justice of the Peace, Commissioner for Declarations,
or a person before whom a Statutory Declaration may be made
under the Statutory Declarations Act 1959. Outside Australia, a
person who is equivalent to a Justice of the Peace or a
Commissioner for Declarations must certify copies.
If you do not provide all the necessary documents, a
decision may be made on the information you have
provided. It is in your interest to support your
application with as much information as possible at the
time of application.
If you are not able to provide any of the documents listed
at Part Q, please provide a written explanation why the
documents are not available.
Under no circumstances should you submit false
documents.
Where can you lodge this application?
Applicants wishing to be considered for a Class XB visa in the
Refugee category must lodge their form at an Australian overseas
mission. For addresses, please see the department’s website
www.border.gov.au/about/contact/offices-locations
Applicants wishing to be considered for a Class XB visa under the
Global Special Humanitarian Programme (subclass 202), the ‘split
family’ provisions for immediate family members or the
Community Proposal Pilot must lodge this form as follows:
Applicants residing in the Middle East* and all applicants
in the Community Proposal Pilot
Victoria Special Humanitarian Processing Centre
By Post:
GPO Box 241
Melbourne VIC 3001
AUSTRALIA
By Courier (no hand deliveries)
2 Lonsdale Street
Melbourne VIC 3001
AUSTRALIA
(* Countries include Bahrain, Iran, Iraq, Jordan, Kuwait, Lebanon,
Oman, Qatar, Saudi Arabia, Syria, Turkey, United Arab Emirates
and Yemen.)
Applicants residing in any other country, including
Afghanistan and Pakistan from 1 July 2016
NSW Special Humanitarian Processing Centre
By Post:
GPO Box 9984
Sydney NSW 2001
AUSTRALIA
By Courier (no hand deliveries)
26 Lee Street
Sydney NSW 2001
AUSTRALIA
For further information, please see the information sheet
Lodging Certain Humanitarian Applications in Australia
available from the department’s website www.border.gov.au
© COMMONWEALTH OF AUSTRALIA, 2016
Is there an application or processing charge?
Applicants in the Community Proposal Pilot must pay a Visa
Application Charge. Please refer to the Visa Pricing Table
www.border.gov.au/trav/visa/fees
Other applicants do not have a charge to lodge this application.
Is there a charge for the form?
No – forms 681, 842 and 1417 are free and may be obtained from
any office of the department in Australia and overseas or from
the department’s website www.border.gov.au/allforms/
Interviews and requests for more information
Interviews are not always necessary. We will advise you if you are
required to attend an interview or if you need to provide more
documents or information.
Change of circumstances
If your circumstances change in any way after you have lodged
this form (eg. if you or a family member enters into a new
relationship, becomes engaged, or marries), you must inform the
office where the application was lodged. If a child is born to
you (or any other person included in this application)
after the application is lodged, the child will be included
in your application if details are provided before a final
decision is made on your application.
Processing information
You should be aware that there is strong interest in this class of
visa and it may take a long time to finalise your application.
You may need to have a medical and an x-ray examination as part
of the assessment of your application. You may also be asked to
undergo medical treatment as part of the assessment of the visa
application. The Australian Government reserves the right to
conduct character checks on all adult applicants. Details of your
application are not passed on to your home country.
The Australian Government will pay the costs related to medical
examinations for all humanitarian visa applicants, except visa
applicants in the Community Proposal Pilot. All visa subclasses,
except Global Special Humanitarian (subclass 202) visa holders
and visa holders in the Community Proposal Pilot, will also have
their travel costs paid by the Australian Government.
Note: For applicants in the Community Proposal Pilot, the APO
must pay the costs of medical examinations and, if a visa is
granted, the cost of airfares to Australia.
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.
The department is careful to protect the privacy of all applicants.
Care will be taken to make sure that details of your application
do not reach your home country.
Review rights
If your application is refused, it is not possible to obtain a review
of the decision by the Administrative Appeals Tribunal.
842 (Design date 07/16) - Page 3
Settlement services
If you are granted a humanitarian visa (subclasses 200, 201, 202,
203 or 204), information on the personal possessions that you
may take with you to Australia is available from the office that
granted your visa.
The Australian Government provides a range of services to help
refugee and humanitarian entrants settle in Australia. This
assistance may include being met on arrival by a service provider
and taken to accommodation, help to register for income
support, help to arrange medical appointments, information
about your new community, and attending English language
classes.
Note: If you are granted a humanitarian visa in the Community
Proposal Pilot, settlement services will be provided to you by
your APO, in conjunction with any Supporting Community
Organisation.
Immigration assistance
A person gives immigration assistance to you if he or she uses, or
claims to use, his or her knowledge or experience in migration
procedure to assist you with your visa application, request for
ministerial intervention, cancellation review application,
sponsorship or nomination.
In Australia a person may only lawfully give immigration
assistance if he or she is a registered migration agent or is exempt
from being registered. Only registered migration agents may
receive a fee or reward for providing immigration assistance.
If an unregistered person in Australia, who is not exempt from
registration, gives you immigration assistance they are
committing a criminal offence and may be prosecuted.
Restrictions on giving immigration assistance, charging fees for
immigration assistance and restrictions on charging fees for
immigration representations apply even where the APO lodges
form 842 (this form) on behalf of a client in the Community
Proposal Pilot.
Migration agents in Australia
Migration agents in Australia must be registered with the Office
of the Migration Agents Registration Authority (Office of the
MARA) unless they are exempt from registration.
Migration agents outside Australia
Migration agents who operate outside Australia do not have to be
registered. The department may give some overseas agents an ID
number. This number does not mean that they are registered.
Note: Some Australian registered migration agents operate
overseas.
842 (Design date 07/16) - Page 4 © COMMONWEALTH OF AUSTRALIA, 2016
Migration agent information
A migration agent is someone who can:
• advise you on the visa that may best suit you;
• tell you the documents you need to submit with your
application;
• help you fill in the application and submit it; and
• communicate with the department on your behalf.
If you appoint a migration agent, the department will assume
that your migration agent will be your authorised recipient,
unless you indicate otherwise.
Your migration agent will be the person with whom the
department will discuss your application and from whom it will
seek further information when required.
You are not required to use a migration agent. However, if you
use a migration agent, the department encourages you to use a
registered migration agent. Registered agents are bound by the
Migration Agents Code of Conduct, which requires them to act
professionally in their clients’ lawful best interests.
Information on migration agents, including a list of registered
migration agents, is available on the Office of the MARA website
www.mara.gov.au
You can also access information about migration agents on the
department’s website www.border.gov.au
Exempt persons
The following people do not have to be a registered migration
agent in order to provide immigration assistance, but they must
not charge a fee for their service:
• a close family member (spouse, de facto partner, child, parent,
brother or sister);
• a member of parliament or their staff;
• an official whose duties include providing immigration
assistance (eg. a Legal Aid provider);
• a member of a diplomatic mission, consular post or
international organisation.
Appointing a migration agent/exempt person
To appoint a migration agent/exempt person you should complete
Part M – Options for receiving written communications.
Your migration agent/exempt person should complete form 956
Advice by a migration agent/exempt person of providing
immigration assistance.
Form 956 is available from the department’s website
www.border.gov.au/allforms/
Options for receiving written communications
If you do not appoint a migration agent/exempt person you may
still authorise another person, in writing, to receive written
communications on your behalf. This person is called the
authorised recipient.
Authorised recipient information
All written communication about your application will be sent to
your authorised recipient, unless you indicate that you wish to
have health and/or character information sent directly to you. If
your visa application is subject to proposal form 681 or form 1417
and you wish all written communication to be sent to your
proposer, you will need to complete Question 17 and
Question 46 on this form.
The department will communicate with the most recently
appointed authorised recipient as you may only appoint one
authorised recipient at any time for a particular application.
You will be taken to have received any documents sent to that
person as if they had been sent to you.
Consent to communicate electronically
The department may use a range of means to communicate with
you. However, electronic means such as fax or email will only be
used if you indicate your agreement to receiving communication
in this way.
To process your application the department may need to
communicate with you about sensitive information, for example,
health, police checks, financial viability and personal
relationships. Electronic communications, unless adequately
encrypted, are not secure and may be viewed by others or
interfered with.
If you agree to the department communicating with you by
electronic means, the details you provide will only be used by the
department for the purpose for which you have provided them,
unless there is a legal obligation or necessity to use them for
another purpose, or you have consented to use for another
purpose. They will not be added to any mailing list.
The Australian Government accepts no responsibility for the
security or integrity of any information sent to the department
over the internet or by other electronic means.
If you authorise another person to receive documents on your
behalf and they wish to be contacted electronically, their
signature is required on form 956, form 956A, form 681 or
form 1417 to indicate their consent to this form of
communication.
Note: Electronic communication is the fastest means of
communication available and the department prefers to
communicate electronically because this results in faster
processing.

Home page www.border.gov.au

General Telephone 131 881 during business hours
enquiry line in Australia to speak to an operator (recorded
information available outside these hours).
If you are outside Australia, please contact
your nearest Australian mission.

Please keep these information pages for your reference

© COMMONWEALTH OF AUSTRALIA, 2016 842 (Design date 07/16) - Page 5
This page is intentionally blank
 Application for an Form

Offshore Humanitarian visa 842

Refugee and Humanitarian (Class XB) visa

Please use a pen, and write neatly in English using BLOCK LETTERS.
PHOTOGRAPH
Tick where applicable 3 Please attach eight (8)
recent passport sized
Part A – Summary of people included in this application photographs of yourself
• Only include members of your family who are dependent on you or your partner. AND
• A dependant is a person who is wholly or substantially dependent on you or your partner for financial, psychological or all members of your
physical support. family unit included in this
application
• The term ‘partner’ in this form, means your spouse or de facto partner (including same-sex partners).
Note: Clearly write the
• Non-dependent family members (eg. adult independent children, married children or children over 18 who have their name of the person on the
own income) should complete their own application form. However you should still list any non-dependent children at back of each photograph
Question 13 and Question 14 of Part D on this form.
• You must attach evidence of the identity of each person (eg. certified copy of birth certificate, marriage certificate,
passport), wherever this is available. If you do not have identity documents, please attach an explanation as to why you
no longer have them.
• For each person included who is not the main applicant’s partner or child under 18 years, you must attach a statement
explaining why this person is dependent on the main applicant.
• It is important that all names are spelled correctly and dates of birth are accurate.

1 How many people are included in this application? 4 Relationship status

Married legally Engaged Widowed
2 Give details of the main applicant Married by De facto Never married or
A1
Family name ASHI tradition/custom Separated been in a de facto
relationship
Married religiously ✔ Divorced
Given names ZAFER
For your relationship status (other than ‘never married or been in a
Name in own de facto relationship’), give the following details:
language or Day Month Year
ethnic script
Date this happened 23-Jul-1993
Sex Male ✔ Female
Day Month Year Place this happened HOMS
Date of birth 25-Jun-1963 Your previous name (if applicable)

Place of birth Town/city HOMS

Do you currently have more than one partner (other than any partner
Country SYRIA included in this visa application)?
Citizenship SYRIA No ✔
If stateless, write your previous country of citizenship Yes Please provide details
Current country of BRAZIL
residence
Day Month Year
Date you arrived in 29-Sep-2014
this country
Select
Status in this country R See below for codes to be used
If you have indicated you are ‘never married or been in a de facto
relationship’ or ‘engaged to be married’, are you currently in any other
form of a relationship (eg. boyfriend/girlfriend)?
‘Status in this country’ codes No ✔
C = Citizen
PR = Permanent resident Yes Please provide details
TR = Temporary resident
S = Student
V = Visitor/Tourist
R = Refugee
I = Illegal resident
A = Asylum/protection applicant
O = Other – give details on a separate page

© COMMONWEALTH OF AUSTRALIA, 2016 842 (Design date 07/16) - Page 7

3 Give details of all other people included in this application
1. Family name JABBOUR A2 2. Family name ASHI A3

Given names GHADA Given names ROJER

Name in own Name in own
language or language or
ethnic script ethnic script
Sex Male Female ✔ Sex Male ✔ Female
Day Month Year Day Month Year

Date of birth 12-Feb-1967 Date of birth 01-Sep-1994

Place of birth Town/city HAMA Place of birth Town/city HOMS

Country SYRIA Country SYRIA

Citizenship SYRIA Citizenship SYRIA
If stateless, write your previous country of citizenship If stateless, write your previous country of citizenship
Relationship status Relationship status
Married legally Engaged Widowed Married legally Engaged Widowed
Married by De facto Never married or Married by De facto Never married or ✔
tradition/custom Separated been in a de facto tradition/custom Separated been in a de facto
relationship relationship
Married religiously ✔ Divorced Married religiously Divorced
Relationship to His wife Relationship to
main applicant main applicant
Is this person biologically related to the main applicant? Is this person biologically related to the main applicant?
No Explain how they are related to the main applicant No ✔ Explain how they are related to the main applicant

Yes ✔ Describe the precise biological relationship Yes Describe the precise biological relationship
His wife

842 (Design date 07/16) - Page 8 © COMMONWEALTH OF AUSTRALIA, 2016

3. Family name ASHI A4 4. Family name A5

Given names ANDRE Given names

Name in own Name in own
language or language or
ethnic script ethnic script
Sex Male ✔ Female Sex Male Female
Day Month Year Day Month Year

Date of birth 10-May-1999 Date of birth

Place of birth Town/city HOMS Place of birth Town/city

Country SYRIA Country

Citizenship SYRIA Citizenship

If stateless, write your previous country of citizenship If stateless, write your previous country of citizenship
Relationship status Relationship status
Married legally Engaged Widowed Married legally Engaged Widowed
Married by De facto Never married or ✔ Married by De facto Never married or
tradition/custom Separated been in a de facto tradition/custom Separated been in a de facto
relationship relationship
Married religiously Divorced Married religiously Divorced
Relationship to Relationship to
main applicant main applicant
Is this person biologically related to the main applicant? Is this person biologically related to the main applicant?
No ✔ Explain how they are related to the main applicant No Explain how they are related to the main applicant

Yes Describe the precise biological relationship Yes Describe the precise biological relationship

© COMMONWEALTH OF AUSTRALIA, 2016 842 (Design date 07/16) - Page 9

 5. Family name A6 6. Family name A7

Given names Given names

Name in own Name in own
language or language or
ethnic script ethnic script
Sex Male Female Sex Male Female
Day Month Year Day Month Year

Date of birth Date of birth

Place of birth Town/city Place of birth Town/city

Country Country

Citizenship Citizenship
If stateless, write your previous country of citizenship If stateless, write your previous country of citizenship
Relationship status Relationship status
Married legally Engaged Widowed Married legally Engaged Widowed
Married by De facto Never married or Married by De facto Never married or
tradition/custom Separated been in a de facto tradition/custom Separated been in a de facto
relationship relationship
Married religiously Divorced Married religiously Divorced
Relationship to Relationship to
main applicant main applicant
Is this person biologically related to the main applicant? Is this person biologically related to the main applicant?
No Explain how they are related to the main applicant No Explain how they are related to the main applicant

Yes Describe the precise biological relationship Yes Describe the precise biological relationship

If you need more space, please attach a separate page with the details
Attach evidence of identity of each person included in this application
(eg. certified copies of birth certificates, marriage certificates,
passport, national identity card)

842 (Design date 07/16) - Page 10 © COMMONWEALTH OF AUSTRALIA, 2016

 Part B – Mandated or registered applicants
4 Has any person included in this application been mandated as a refugee or
registered with the United Nations High Commissioner for Refugees (UNHCR)?
No ✔
Yes Give details
Name Refugee Mandate number(s) Country of mandate

Name Refugee Registration number(s) Country of registration

Attach a certified copy of evidence of your mandate/registration

Part C – Contact details

5 Your current residential address (not postal address) 7 Do you agree to the department communicating with you by fax, email,
Note: You must tell us if your address changes after you lodge this form. or other electronic means?
No
BRAZIL\ SAO PAULO\ MOGI GUACU
Yes ✔ Give details
R.JOSE DE PAULA\128 Country code Area code Number
Postal code 13840050 Fax number ( ) ( )

Email address ROJER.944@HOTMAIL.COM

6 Address where we should write to you about this application if different
from your residential address Note: If you wish to nominate a person other than yourself to receive
Note: You must tell us if your address changes after you lodge this form. written communications about this application, you must indicate this at
Part M.
BRAZIL\ SAO PAULO\ MOGI GUACU
R.JOSE DE PAULA\128

Postal code 13840050

Your contact telephone numbers (if available)
Country code Area code Number
Telephone ( 0055 ) ( 19 ) 38419205
number
Mobile/cell 005519996081864

© COMMONWEALTH OF AUSTRALIA, 2016 842 (Design date 07/16) - Page 11

 Part D – Family background 3. Family name

8 Have you or any other person included in this visa application Given names
previously been legally married, in a de facto relationship or in a Previous partner’s full name
customary/traditional/religious marriage that is not legally recognised?
No ✔
Day Month Year
Yes Give details of each person below
Dates of
Note: Include partners who you are divorced or separated relationship From
from or who are missing or deceased.
To
1. Family name How did the relationship end?

Given names
Previous partner’s full name Names of all children from this previous relationship

Day Month Year

Dates of
relationship From

To If you need more space, please attach a separate page with the details
How did the relationship end? Attach a certified copy of previous marriage/divorce documents or
death certificate (if applicable/available)

Names of all children from this previous relationship
9 Do you or any other person included in this application have children
from a previous marriage/relationship, including customary/traditional
marriage?
No ✔
Yes Do they have sole custody of any children under 18 years of
age who are included in this application?

2. Family name No Yes Attach a certified copy of the

custody documents (if available)
Given names Note: Where custody documents are not provided or
assessed as unsatisfactory, the former partner will need to
Previous partner’s full name
provide evidence that he/she consents to any children of
that relationship entering Australia.
Day Month Year
Dates of
relationship From

To
How did the relationship end?

Names of all children from this previous relationship

842 (Design date 07/16) - Page 12 © COMMONWEALTH OF AUSTRALIA, 2016

10 Are there any children included in this application who are not the 3. Family name
biological children of either you (the main applicant) or your partner?
No ✔ Given names
Yes Give details of each child Day Month Year

Date of birth
1. Family name
Relationship
Given names to you
Full name of biological father
Day Month Year

Date of birth
Relationship Full name of biological mother
to you
Full name of biological father
Whereabouts of biological parents
(if deceased or unknown, please state)
Full name of biological mother

Whereabouts of biological parents

(if deceased or unknown, please state)
Has this child been adopted (formally, customarily or traditionally)
by the main applicant and/or partner?
No
Yes Date custody commenced
Day Month Year
Has this child been adopted (formally, customarily or traditionally)
by the main applicant and/or partner?
No If you need more space, please attach a separate page with the details
Yes Date custody commenced For each adopted child, attach a certified copy of the adoption
Day Month Year
papers (if available) or attach a statement which explains the
circumstances of the adoption

2. Family name

Given names
Day Month Year

Date of birth
Relationship
to you
Full name of biological father

Full name of biological mother

Whereabouts of biological parents

(if deceased or unknown, please state)

Has this child been adopted (formally, customarily or traditionally)

by the main applicant and/or partner?
No
Yes Date custody commenced
Day Month Year

© COMMONWEALTH OF AUSTRALIA, 2016 842 (Design date 07/16) - Page 13

11 Do you have a husband, wife, de facto partner or any dependants who 12 Is any person included in this application physically separated from you
normally live with you but who are not included in this application? (eg. missing or living at a separate address/location)?
A dependant is a person who is wholly or substantially dependent on No ✔
you or your partner for financial, psychological or physical support. Yes Give details and explain when and where you were last
No ✔ in contact with them
Yes Give details and explain why they do not intend to migrate
with you as part of this visa application 1. Family name

1. Family name Given names

Day Month Year
Given names Date of birth
Day Month Year
Relationship
Date of birth to you
Relationship Last contact (when, where and how you were separated)
to you
Reason they are not applying with you

Full residential address (if known)

Postal code
2. Family name

Given names
2. Family name
Day Month Year

Date of birth Given names

Day Month Year
Relationship
to you Date of birth
Reason they are not applying with you Relationship
to you
Last contact (when, where and how you were separated)

3. Family name Full residential address (if known)

Given names
Day Month Year

Date of birth Postal code

Relationship
to you 3. Family name
Reason they are not applying with you
Given names
Day Month Year

Date of birth
Relationship
to you
If you need more space, please attach a separate page with the details
Last contact (when, where and how you were separated)

Full residential address (if known)

Postal code

If you need more space, please attach a separate page with the details

842 (Design date 07/16) - Page 14 © COMMONWEALTH OF AUSTRALIA, 2016

13 Relatives of MAIN APPLICANT
Give details of ALL YOUR parents, brothers and sisters and non-dependent children. You must include half, step and adopted relatives.
If any person listed below is not biologically related to you, you must clearly indicate this.
Note: You must list ALL relatives, whether they are living, deceased, or their whereabouts are unknown. If any relative is deceased or
missing/whereabouts unknown, then you must write ‘DECEASED’ or ‘UNKNOWN’ in the ‘Country where they are now living’ column.
Relationship Status in ‘Relationship status’ codes
Relationship
Sex Date of birth to main Country where they country of N = Never married or been in a
Name status Place and country of birth applicant are now living residence de facto relationship
(use codes
on right) (use codes (use codes M = Married legally
M/F Day Month Year on right) on right) E = Engaged to be married
Your parents Select Select Select S = Separated
F = In a de facto relationship
SO D = Divorced
W = Widowed
MT = Married by tradition/custom
Mother’s maiden name MR = Married religiously

‘Relationship to main applicant’

Your brothers and sisters Select Select Select codes
PB = Parent – Biological
PA = Parent – Adoptive
PS = Parent – Step
PO = Parent – Other
(attach explanation)
SB = Sibling – Biological (full)
SA = Sibling – Adoptive
SS = Sibling – Step
SO = Sibling – Other
(attach explanation)
CB = Child – Biological
CA = Child – Adoptive
CS = Child – Step
CO = Child – Other
(attach explanation)

‘Status in country of residence’

Your non-dependent children (all children who are not included as dependants in this application) Select Select codes
C = Citizen
PR = Permanent resident
TR = Temporary resident
S = Student
V = Visitor/Tourist
R = Refugee
I = Illegal resident
A = Asylum/protection applicant
O = Other – give details on a
separate page

If you need more space, please attach a separate page listing further names
© COMMONWEALTH OF AUSTRALIA, 2016 842 (Design date 07/16) - Page 15
14 Relatives of main applicant’s PARTNER
Give details of ALL YOUR PARTNER’s parents, brothers and sisters and non-dependent children, including children your partner has had with other partners.
You must include half, step and adopted relatives. If any person listed below is not biologically related to your partner, you must clearly indicate this.
Note: You must list ALL YOUR PARTNER’s relatives, whether they are living, deceased, or their whereabouts are unknown. If any relative is deceased or
missing/whereabouts unknown, then you must write ‘DECEASED’ or ‘UNKNOWN’ in the ‘Country where they are now living’ column.
Relationship Status in ‘Relationship status’ codes
Relationship
Sex Date of birth to main Country where they country of N = Never married or been in a
Name status Place and country of birth applicant are now living residence de facto relationship
(use codes
on right) (use codes (use codes M = Married legally
M/F Day Month Year on right) on right)
E = Engaged to be married
Your partner’s parents Select Select Select S = Separated
F = In a de facto relationship
D = Divorced
W = Widowed
MT = Married by tradition/custom
Your partner’s mother’s maiden name MR = Married religiously

‘Relationship to main applicant’

Your partner’s brothers and sisters Select Select Select codes
PB = Parent – Biological
PA = Parent – Adoptive
PS = Parent – Step
PO = Parent – Other
(attach explanation)
SB = Sibling – Biological (full)
SA = Sibling – Adoptive
SS = Sibling – Step
SO = Sibling – Other
(attach explanation)
CB = Child – Biological
CA = Child – Adoptive
CS = Child – Step
CO = Child – Other
(attach explanation)

‘Status in country of residence’

Your partner’s non-dependent children (all children who are not included as dependants in this application) Select Select codes
C = Citizen
PR = Permanent resident
TR = Temporary resident
S = Student
V = Visitor/Tourist
R = Refugee
I = Illegal resident
A = Asylum/protection applicant
O = Other – give details on a
separate page

If you need more space, please attach a separate page listing further names
842 (Design date 07/16) - Page 16 © COMMONWEALTH OF AUSTRALIA, 2016
 Part E – Links to Australia
15 Has any person included in this application ever applied for an Australian visa (permanent or temporary) before?
No ✔
Yes Give details

Family and given name

Date of application File number Application approved?
(If all persons included in this application, Where was the application lodged?
(if known)
write ‘All’) Day Month Year No Yes Not decided

If you need more space, please attach a separate page with the details

16 Do you or your partner have any relatives NOT INCLUDED IN THIS VISA APPLICATION who have current Australian visa applications under consideration?
No ✔
Yes Give details

Date of application File number Type of visa application

Family and given name Where was the application lodged?
Day Month Year (if known) (if known)

If you need more space, please attach a separate page with the details

17 Is any person included in this application being proposed (on form 681 or form 1417) for entry to Australia by a person or organisation in Australia?
No ✔
Yes Give details of your proposer or Approved Proposing Organisation (in case of a Community Proposal Pilot application)
Family name

Given names
OR
Organisation name

Contact person

Relationship of the
proposer to you
Address of proposer

Postcode

Telephone number (Area code )

Note: Proposers in the Global Special Humanitarian (subclass 202) programme must complete form 681 Refugee and Special Humanitarian
Proposal and lodge both form 681 and this form (form 842) together. There is no charge for lodging or processing form 681.
Note: APOs under the Community Proposal Pilot must complete form 1417 Proposal for refugee and special humanitarian entrants by
Approved Proposing Organisation and lodge both form 1417 and this form (form 842) together. For charges associated with lodging and
processing form 1417, refer to the Visa Pricing Table www.border.gov.au/trav/visa/fees
These forms are available from the department’s website www.border.gov.au

© COMMONWEALTH OF AUSTRALIA, 2016 842 (Design date 07/16) - Page 17

18 ‘Split family’ provisions for ‘immediate family’ members
Are any people included in this application members of the immediate family of a person in Australia who, in the last 5 years,
was granted a Refugee/Humanitarian visa outside Australia, or a Protection or Resolution of Status (Class CD) visa inside Australia?
‘Immediate family’ means a spouse or de facto partner (including same-sex partner), dependent children,
or parent (if your child in Australia is under 18 years of age)
No ✔
Yes Give details of the immediate family member who was granted the visa
Family name

Given names

File number (if known)

Name of the person in this
application they are related to
Relationship

Where did they last live together?

Day Month Year

When did they last live together?

How did they become separated?

Attach a completed form 681 Refugee and Special Humanitarian Proposal to this application (there is no charge
for lodging or processing form 681)
Your proposer should complete form 681 for lodgement with this visa application. Form 681 is available from
any office of the department, or from the department’s website www.border.gov.au
Attach a certified copy of the immediate family member’s Australian visa and evidence of the relationship
(eg. a marriage certificate, birth certificate etc.) if available
Provide details of humanitarian claims at Part G, Questions 24 – 36

842 (Design date 07/16) - Page 18 © COMMONWEALTH OF AUSTRALIA, 2016

19 Do any people included in this application have any other relatives residing in Australia?
No
Yes ✔ Give details Select
Details of the relative in Australia Details of the person in this application they are related to
Relationship
Date of birth status in
Name Australia Address Given names Relationship to applicant
(use codes
Day Month Year below)

1. ACHI 10-Sep-1950 PR 76 HAWKSVIEW STREET GUILDFORD,NSW 2161 GEORGE MY BRATHER

AUSTRALIA

2.

3.

4.

5.

If you need more space, please attach a separate page with the details

20 Do any people included in this application have any other past or present links to Australia?
No ✔
Yes Indicate the types of links and give details
Links: Education Employment Business Friend Other

Details

‘Resident status in Australia’ codes

C = Citizen
PR = Permanent resident
TR = Temporary resident
S = Student
V = Visitor/Tourist
I = Illegal resident
U = Unlawful non-citizen
O = Other – give details on a separate page

© COMMONWEALTH OF AUSTRALIA, 2016 842 (Design date 07/16) - Page 19

 Part F – Background information A3 Given names ROJER
Does this person have a travel or identity document?
21 Give details of any valid travel documents (eg. passports) or identity
cards/documents held by all people included in this application No Attach a statement explaining what happened
to your documents
Note: If you do not have any documents, please explain why – do not
obtain fraudulent documents. Yes ✔ Give details Select
Type of document P
A1 Main applicant
(use codes below)
Passport number 008593086
Do you have a travel or identity document? (or document number)

No Attach a statement explaining what happened Country of issue SYRIA

to your documents
Day Month Year
Yes ✔ Give details
Select Date of issue 28-Sep-2013
Type of document P
(use codes below) Date of expiry 27-Sep-2015
Passport number N 009234735
(or document number) Issuing authority/place of issue as shown in passport (or other document)
Country of issue SYRIA HOMS-CENTER
Day Month Year

Date of issue 28-May-2014

A4 Given names ANDRE
Date of expiry 27-May-2020
Does this person have a travel or identity document?
Issuing authority/place of issue as shown in passport (or other document)
No Attach a statement explaining what happened
HOMS-CENTER to your documents
Yes ✔ Give details Select
Type of document P
Other applicants (use codes below)
Passport number
A2 Given names GHADA (or document number)
009148771

Does this person have a travel or identity document? Country of issue SYRIA
No Attach a statement explaining what happened Day Month Year
to your documents
Date of issue 12-May-2014
Yes ✔ Give details Select
Type of document Date of expiry 11-May-2016
P
(use codes below)
Issuing authority/place of issue as shown in passport (or other document)
Passport number N 009177236
(or document number)
HOMS -CENTER
Country of issue SYRIA
Day Month Year

Date of issue 15-May-2014 A5 Given names

Date of expiry 14-May-2020 Does this person have a travel or identity document?
No Attach a statement explaining what happened
Issuing authority/place of issue as shown in passport (or other document)
to your documents
HOMS-CENTER Yes Give details Select
Type of document
(use codes below)
Passport number
(or document number)

Country of issue
Day Month Year

Date of issue

Date of expiry
Issuing authority/place of issue as shown in passport (or other document)
‘Type of document’ codes
P = Passport
UN = UN Convention travel document or Titre de voyage
A = Alien/Asylum Registration Card
CI = Certificate or document of identity
S = Seafarer identity document
NIC = National identity card

842 (Design date 07/16) - Page 20 © COMMONWEALTH OF AUSTRALIA, 2016

 A6 Given names

Does this person have a travel or identity document?

No Attach a statement explaining what happened
to your documents
Yes Give details
Select
Type of document
(use codes below)
Passport number
(or document number)

Country of issue
Day Month Year

Date of issue

Date of expiry
Issuing authority/place of issue as shown in passport (or other document)

A7 Given names

Does this person have a travel or identity document?

No Attach a statement explaining what happened
to your documents
Yes Give details
Select
Type of document
(use codes below)
Passport number
(or document number)

Country of issue
Day Month Year

Date of issue

Date of expiry
Issuing authority/place of issue as shown in passport (or other document)

If you need more space, please attach a separate page with the details
Attach certified copies of the travel documents and identity
documents, if available

‘Type of document’ codes

P = Passport
UN = UN Convention travel document or Titre de voyage
A = Alien/Asylum Registration Card
CI = Certificate or document of identity
S = Seafarer identity document
NIC = National identity card

© COMMONWEALTH OF AUSTRALIA, 2016 842 (Design date 07/16) - Page 21

22 Has any person included in this application applied to migrate to another country, or applied for refugee resettlement or asylum in any country?
No ✔
Yes Give details

Family and given names Type of application

Date of application Application approved?
(If all persons included in this application, Which country? (eg. refugee resettlement,
write ‘ALL’) Day Month Year migration, asylum etc.) No Yes Not decided

If you need more space, please attach a separate page with the details

23 For EACH person included in this application list every address where they have lived during the last 10 years
Date you started to live
Given names of people included in this application
Address where you are living now at this address
who live at this address (if all, write ‘ALL’)
Day Month Year

SYRIA\HOMS\R.AL KARM 09-Aug-2010 ZAFER

GAHDA
ROJER
Town Country ANDRE

Period at this address Given names of people included in this application

Previous addresses
Month Year who live at this address (if all, write ‘ALL’)
1. From

To

Town Country

2. From

To

Town Country

3. From

To

Town Country

4. From

To

Town Country

5. From

To

Town Country

Attach certified copies of any visas/residence permits held by your family

842 (Design date 07/16) - Page 22 © COMMONWEALTH OF AUSTRALIA, 2016

 Part G – Humanitarian claims
• Your application will be assessed against the following 4 factors:
–– the degree of persecution or discrimination to which you are subject in your home country
–– the extent of your connection with Australia
–– whether or not there is any suitable country available, other than Australia, that can provide for your settlement and protection from discrimination
–– the capacity of the Australian community or (in the case of a Community Proposal Pilot application) any proposers of your application, to provide for the
permanent settlement of persons such as you in Australia.
All applicants should include as much information as possible about these factors.
• Not all applicants are interviewed.
• Your answers should pay special attention to what happened to you and your family, not to the general situation in the country you fear returning to.
• When answering, you should tell us everything about why you and your family think you should be considered for entry to Australia under the Humanitarian
Programme.
• In answering these questions, you should tell us if you think any events/occurrences you refer to are because of:
–– your race
–– your religion
–– your nationality
–– your membership of a particular social group
–– your political opinion
–– other reasons.
• You should, wherever possible, provide as much information relating to dates, locations etc. in respect of any events/occurrences to which you refer.

24 For ALL the people included in this application list the ethnic group to which they belong, their religion and any political party/group to which they belong
Membership of political party/group
Given names Ethnic group or clan Religion (if any)
(if any)

A1 Main applicant Christian

Other applicants
A2 GHADA Christian

A3 ROJER Christian

A4 ANDRE Christian

A5

A6

A7

If you need more space, please attach a separate page with the details
© COMMONWEALTH OF AUSTRALIA, 2016 842 (Design date 07/16) - Page 23
25 What is the name of the country you fear living in or returning to?
SYRIA

26 Have you left the country you fear living in?

No
Yes ✔ Date you left
Day Month Year
29-Sep-2014

27 Why do you fear living in or returning to the country you listed at Question 25?
Your answer should pay special attention to what happened to you, not the general situation in that country.
HI :
We are from syria and we escaped to brazil because of the war . we lost our house and now we do not have any thing . all houses
in our street have destroyed. we escaped to save our two young boys because they have asked to go to the army. we are christian,
neither syrian government nor islamic opposition, can save us in Brazil we do not get any aids and we are afraid from sending us
to Syria. The situation here is bad because of demonstrations we can not find work and the security state is not good . we do not
feel safety . And my brother lives in Australia and we need to go there , and Because the security situation is not stable in Brazil,
my brother in Australia too scared us and is calling for him to go .

thanks.

If you need more space, please attach a separate page with the details

842 (Design date 07/16) - Page 24 © COMMONWEALTH OF AUSTRALIA, 2016

28 If you have left the country you fear, how did you leave?
Legally ✔ Give details of your exit permit
We fled from Syria to Lebanon, then to Brazil
Illegally Describe how you arranged to leave illegally

29 What do you believe may happen to you, or the people included in your application, if you were to return to or continue living in that country?
You should give full details of what you think may happen to you and reasons why that would happen

We are afraid to return to our country because of the war and the armed Islamist groups deployed there and because of that we
Christians are persecuted minority

If you need more space, please attach a separate page with the details

30 Who do you think may harm or mistreat you if you continue living in or go back to that country?

If you need more space, please attach a separate page with the details
© COMMONWEALTH OF AUSTRALIA, 2016 842 (Design date 07/16) - Page 25
31 Do you think the authorities of that country can and will protect you if you continue living in or return to that country?
No ✔ Please explain why
Yes

32 Did you travel through, or stay, in any other countries before arriving in the country where you are now living?
No
Yes ✔ Give details including length of stay and dates
Date
Country From To
Day Month Year Day Month Year

Lebanon 27-Sep-2014 29-Sep-2014

33 Has this application been lodged based on the United Nations High Commissioner for Refugees (UNHCR) referring you to Australia for refugee resettlement?
No ✔
Yes Attach a full copy of your UNHCR Resettlement Registration Form (RRF)

34 Has any person included in this application served in a military organisation (army/airforce/navy) or in a paramilitary organisation?
No ✔
Yes Give details

1. Given name 2. Given name

Country served Country served

Name of military/paramilitary organisation Name of military/paramilitary organisation

Rank in this Rank in this

organisation organisation
Day Month Year Day Month Year
Dates of Dates of
membership From membership From
of this of this
organisation To organisation To
Why did this person leave this organisation? Why did this person leave this organisation?

If you need more space, please attach a separate page with the details
Attach certified copies of any discharge papers if available

842 (Design date 07/16) - Page 26 © COMMONWEALTH OF AUSTRALIA, 2016

35 Has any person included in this application ever lived in a refugee camp, collective accommodation centre for refugees, or detention centre?
No ✔
Yes Give details
Given names of people included in this
Who ran the Dates lived there
Name of camp/centre Location application who lived there
camp/centre?
Day Month Year (if all, write ‘ALL’)

1. From

To

2. From

To

3. From

To

4. From

To

5. From

To

6. From

To

If you need more space, please attach a separate page with the details

36 If selected for an interview about your application, will you need an interpreter?
No
Yes ✔ Which language(s)?
ARABIC - French
If you are selected for an interview we will advise you if you are required to provide your own interpreter

© COMMONWEALTH OF AUSTRALIA, 2016 842 (Design date 07/16) - Page 27

 Part H – Employment history
37 For EACH person included in this application, list all the jobs that they have had in the last 15 years and show any periods of unemployment
For each person, start with the latest period of employment and work backwards
Dates of employment
Name of employer Location of employer Type of business Occupation and main duties
Day Month Year

A1 Main applicant

From 09-Nov-1986 ZAFER HOMS electronic engineer

To 05 07 2014
From

To

From

To

From

To

From

To

From

To

Other applicants
A2 Name GHADA

From 03-May-1987 GHADA HOMS French teacher

To 09 04 2014
From

To

From

To

From

To

From

To

A3 Name

From

To

From

To

From

To

A4 Name

From

To

From

To

From

To

842 (Design date 07/16) - Page 28 © COMMONWEALTH OF AUSTRALIA, 2016

(Question 37 continued)
Dates of employment
Name of employer Location of employer Type of business Occupation and main duties
Day Month Year

A5 Name

From

To

From

To

From

To

From

To

A6 Name

From

To

From

To

From

To

From

To

A7 Name

From

To

From

To

From

To

From

To

Name

From

To

From

To

From

To

Name

From

To

From

To

From

To

If you need more space, please attach a separate page with the details
© COMMONWEALTH OF AUSTRALIA, 2016 842 (Design date 07/16) - Page 29
 Part I – Language and education
38 For EACH person included in this application, give details of their language Select
How well this person
Given names Main language spoken Other languages spoken speaks English
(insert code from below)

A1 Main applicant ARABIC FRENCH 2

Other applicants
A2 GHADA ARABIC FRINCH 2

A3 ROJER ARABIC ENGLISH 3

A4 ANDRE ARABIC ENGLISH 4

A5

A6

A7

If you need more space, please attach a separate page with the details

39 For EACH person included in this application, give details of their education
Highest educational
Primary school Secondary school Post-secondary education qualification obtained
Given names
(eg. school certificate, electrician
Day Month Year Day Month Year Day Month Year certificate, BA, PhD)

A1 Main applicant From 09-Jul-1982 From From ELECTRONIC

To 02-Jun-1986 To To

Other applicants
A2 GHADA From 09-Mar-1985 From From
French teacher
To 06 01 1987 To To

A3 ROJER From 04-Jun-2012 From From Computer

To 04 06 2014 To To technologies

A4 ANDRE From From From Student

To To To

A5 From From From

To To To

A6 From From From

To To To

A7 From From From

To To To

From From From

To To To

From From From

To To To

If you need more space, please attach a separate page with the details
English language codes
1 = Very well (eg. can speak English with little hesitation and few errors in most situations)
2 = Well (eg. can speak English well enough to deal with basic social and work situations)
3 = Not well (eg. can speak only a little English)
4 = Not at all

842 (Design date 07/16) - Page 30 © COMMONWEALTH OF AUSTRALIA, 2016

 Part J – Health • had any outstanding debts to the Australian
Government or any public authority in
40 Have you, or any other person included in this application, undertaken a Australia? No ✔ Yes
health examination for an Australian visa in the last 12 months? If you answered ‘Yes’ to any of the questions at Question 41, provide all
No ✔ details below. If the matters relate to a criminal conviction, please give
the nature of the offence, full details of sentence and dates of any period
Yes Give details (including HAP ID if available)
of imprisonment or other detention.

Part K – Character
41 Has any person included in this application ever:
• been charged with any offence that is
currently awaiting legal action? 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? 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
If you need more space, please attach a separate page with the details
• 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

© COMMONWEALTH OF AUSTRALIA, 2016 842 (Design date 07/16) - Page 31

 Part L – Assistance with this form Part M – Options for receiving written
42 Did you receive assistance (other than clerical or translation assistance)
communications
in completing this form?
46 All written communications about this application should be sent to:
No ✔ Go to Part M (Tick one box only)
Yes Please give details of the person or organisation who
Myself ✔
assisted you
OR
Title: Mr Mrs Miss Ms Other
Proposer All written communications will be sent to the
Family name address of the proposer provided in this form.
OR Note: If you are applying in the Community
Given names Proposal Pilot, you should select this option.

Organisation Authorised You should complete form 956A Appointment

recipient or withdrawal of an authorised recipient
Address
OR

Migration agent Your migration agent/exempt person should

complete form 956 Advice by a migration
Postcode OR agent/exempt person of providing immigration
Exempt person assistance
Telephone number or daytime contact
Country code Area code Number

Office hours ( ) ( )

Mobile/cell

43 Is the person an agent registered with the Office of the Migration Agents
Registration Authority (Office of the MARA)?
No ✔
Yes Go to Part M

44 Is the person/agent in Australia?

No Go to Part M
Yes ✔

45 Did you pay the person/agent and/or give a gift for this assistance?
No ✔
Yes

842 (Design date 07/16) - Page 32 © COMMONWEALTH OF AUSTRALIA, 2016

 Part N – Australian values statement
47 AUSTRALIAN VALUES STATEMENT
Signature
This statement must be signed by the main applicant and each person of main
aged 18 years or over who is included in this application.
I confirm that I have read, or had explained to me, information provided
applicant -
by the Australian Government on Australian society and values.
I understand: Signature of
• Australian society values respect for the freedom and dignity of the dependent
individual, freedom of religion, commitment to the rule of law, applicant -
Parliamentary democracy, equality of men and women and a spirit of
egalitarianism that embraces mutual respect, tolerance, fair play and Name
compassion for those in need and pursuit of the public good;
• Australian society values equality of opportunity for individuals, Signature of
regardless of their race, religion or ethnic background; dependent
• the English language, as the national language, is an important applicant -
unifying element of Australian society.
I undertake to respect these values of Australian society during my stay Name
in Australia and to obey the laws of Australia.
I understand that, if I should seek to become an Australian citizen: Signature of
dependent
• Australian citizenship is a shared identity, a common bond which
unites all Australians while respecting their diversity;
applicant -
• Australian citizenship involves reciprocal rights and responsibilities. Name
The responsibilities of Australian citizenship include obeying
Australian laws, including those relating to voting at elections and
Signature of
serving on a jury.
dependent
If I meet the legal qualifications for becoming an Australian citizen and
my application is approved I understand that I would have to pledge my
applicant -
loyalty to Australia and its people.
Name

Signature of
dependent
applicant -
Name

Signature of
dependent
applicant -
Name

Signature of
dependent
applicant -
Name

© COMMONWEALTH OF AUSTRALIA, 2016 842 (Design date 07/16) - Page 33

 Part O – Biometrics declaration and consent
48 BIOMETRICS DECLARATION AND CONSENT
Signature
This declaration and consent must be signed by the main applicant and or mark of
each accompanying person aged 16 years or over.
If I am requested or required to provide my fingerprints and facial image:
applicant -
Day Month Year
I consent to:
Date
• the collection of my fingerprints and facial image; and
• if applicable, the collection of the fingerprints and facial image of Signature
each accompanying person under 16 years of age. or mark of
partner
I declare that:
(if applicable) -
• I understand that my fingerprints and facial image and my
Day Month Year
biographical information (and those of each accompanying person
under 16 years of age) held by the department may be given to Date
Australian law enforcement agencies to help identify me and each
accompanying person, to help determine my eligibility and the
Signatures of persons aged 16 years or over who are included in this
eligibility of each accompanying person for grant of the visa applied
application (if applicable)
for, and for law enforcement purposes.
I consent to:
Signature
• Australian law enforcement agencies disclosing my biometric, or mark
biographical and criminal record information (and that of each -
accompanying person under 16 years of age) to the department for Day Month Year
any of the purposes outlined above; and
Date
• the department using the information obtained for the purposes of
the Migration Act 1958 or the Australian Citizenship Act 2007.
Signature
or mark
-
Day Month Year

Date

Signature
or mark
-
Day Month Year

Date

Signature
or mark
-
Day Month Year

Date

Signature
or mark
-
Day Month Year

Date

Signature
or mark
-
Day Month Year

Date

842 (Design date 07/16) - Page 34 © COMMONWEALTH OF AUSTRALIA, 2016

 Part P – Declaration WARNING: Giving false or misleading information is a serious offence.

Signature
Warning: The Migration Act contains a power to cancel a visa if a or mark of
person has made an incorrect statement in relation to their
application. If it is determined that you have concealed information,
applicant -
Day Month Year
such as an offence, your application to enter Australia may be
refused. If you have already been granted a visa and it is Date
subsequently discovered that you have concealed information, such
as an offence, your visa will be liable to cancellation and you may be Signature
refused entry to Australia. In the event that you have already entered or mark of
partner
Australia your visa will be liable to cancellation and, if cancelled, you
may be detained and removed from Australia. (if applicable) -
Day Month Year

Date
49 This declaration must be signed by you (the main applicant) and ALL
persons aged 18 or over included in this application.
Signatures of persons aged 18 years or over who are included in this
I declare that:
application (if applicable)
• the information I have supplied on and with this form is complete,
correct and up-to-date in every detail.
Signature
• I did not marry or enter a de facto relationship to become eligible for
or mark
entry to Australia. -
• I understand that if I have given false or misleading information, my Day Month Year
application may be refused, or, if a visa has been granted, the visa
may be cancelled and I could be removed from Australia. Date
• I understand that if I am granted a visa, any person not included in
this application will not have automatic right of entry to Australia by Signature
way of this application. or mark
• I undertake to inform the Australian Government of any material -
changes to my circumstances while my application is being Day Month Year
considered, or before I am immigration cleared. Date
(Note: Your visa may be cancelled and you could be removed if you
do not advise of changes in circumstances).
• I authorise the Australian Government to make any enquiries Signature
necessary to determine my eligibility for entry to Australia, and to use or mark
any information supplied in this application for that purpose. -
Day Month Year
• I understand that unless my qualifications have already been
recognised by an Australian assessing authority before my departure, Date
they may not be recognised after my arrival.
• I understand that it is my personal responsibility to assess my own
Signature
employment prospects in Australia and acknowledge that labour
or mark
market conditions there can vary significantly from time to time and
between regions.
-
Day Month Year
• I understand that grant of a visa provides no guarantee of
employment once in Australia. Date
• I have read the information contained in form 1442i Privacy notice.
• I understand the department may collect, use and disclose my Signature
personal information (including biometric information and other or mark
sensitive information) as outlined in form 1442i Privacy notice. -
• I understand that information collected in the visa process may be Day Month Year
disclosed to other agencies and contracted service providers for the Date
purposes of evaluating my settlement needs and providing
settlement support.
For applicants applying in the Community Proposal Pilot: Signature
or mark
• I understand that my Approved Proposing Organisation will be
lodging this application on my behalf; and
-
Day Month Year
• I understand that the information that I provide in this form may be
shared with my Approved Proposing Organisation and that my Date
Approved Proposing Organisation may also share this information
with any Supporting Community Organisations it works with in order We strongly advise that you keep a copy of your application
to provide services to help me settle in Australia. and all attachments for your records.

Important: If your circumstances change after you lodge this application (eg. you change your address, marry or become engaged to be married, or have
a baby), you must notify the office where you lodge this application. If your application is supported by a proposal form 681 Refugee and special
humanitarian proposal or form 1417 Proposal for refugee and special humanitarian entrants by Approved Proposing Organisations and your proposer’s
circumstances change after you have lodged this application, you should also notify the office where you lodge this application.
© COMMONWEALTH OF AUSTRALIA, 2016 842 (Design date 07/16) - Page 35
 Part Q – Document checklist Question Document Attached?
Q21 Certified* copies of travel documents and/or
This checklist is provided to help you submit a complete, decision-ready identity cards held by any person included in
application. If you do not have any of the requested documents (originals this application (if available)
or certified* copies) listed below, please provide an explanation as to
OR
why you no longer have these documents.
A statement explaining why you have no
travel/identity documents
UNDER NO CIRCUMSTANCES SHOULD YOU SUBMIT FALSE
DOCUMENTS Q23 Certified* copies of any visas/residence
permits held by any person included in this
50 Have you attached the following documents? application (if available)

Question Document Attached? Q27 A detailed written statement (in English),

clearly explaining the reasons why you fear
Eight (8) recent passport size photographs of living in or returning to your home country
each person included in your application,
with the full name of the person written Q33 If you have been referred for resettlement by
on the back of each photograph the UNHCR, a full copy of your UNHCR
Resettlement Registration Form (RRF)
Q2 & 3 Evidence of the identity of each person
Q34 Certified* copies of any discharge papers
included in this application (eg. certified*
(if available)
copies of birth certificates, marriage
certificates, passport, national identity card
etc.), if available • If you have attached additional pages with answers, each page
Q4 Evidence of registration with any international must be marked with the question number it refers to, and
organisation dealing with refugees signed and dated by each person aged 18 years or over who is
(eg. UNHCR), if applicable included in this application.
• Please ensure you, your partner and persons aged 18 years or over
Q8 Certified* copies of previous marriage/divorce who are included in this application have signed the Declaration at
papers, or death certificates (if applicable) Part P.
Q9 Certified* copies of child custody papers • If you do not provide all the necessary documents, or you have not
(if applicable) provided an adequate explanation why you cannot provide these
documents, a decision may be made on the information you have
Q10 Certified* copies of adoption papers or a provided. It is in your interest to support your application with as
written statement which explains the much information as possible at the time of lodging this application.
circumstances of adoption (if applicable)
• You must lodge your Class XB visa application at the relevant office
Q17 If your entry to Australia is being proposed by of the department responsible for visa applications from your country
a person or organisation in Australia, attach a of residence. To find out which office of the department you need to
fully completed form 681 completed by your lodge your application with, refer to the department’s website at
proposer www.border.gov.au
OR Note: Certain applicants must lodge their application in Australia
(see ‘Where can you lodge this application?’ on page 3).
If your entry to Australia is being proposed by
an Approved Proposing Organisation under
the Community Proposal Pilot, attach a fully
completed form 1417 completed by your
Approved Proposing Organisation
Q18 If you are applying under the ‘split family’
provisions for immediate family members,
please attach:
a certified* copy of your proposer’s visa
evidence of the relationship with your
proposer (eg. a certified* copy of marriage or
birth certificate)
A form 681 completed by your immediate
family member in Australia who is proposing
you
Note: If applying under ‘split family’ provisions,
form 681 must be lodged with the form 842 at
the time you submit this application

* In Australia, copies of documents must be certified as true copies of the original

by a Justice of the Peace, Commissioner for Declarations, or a person before
whom a Statutory Declaration may be made under the Statutory Declarations
Act 1959.
* Outside Australia, copies of documents must be certified by a person who is the
equivalent of a Justice of the Peace or Commissioner for Declarations in the
country where the documents are being certified.
842 (Design date 07/16) - Page 36 © COMMONWEALTH OF AUSTRALIA, 2016