| Page 1 |
Application for an
Offshore Humanitarian visa
Refugee and Humanitarian (Class XB) visa
USTRALIA, 2013
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).
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 program
There are a limited number of places available each year under
the program. In setting the size of the program, 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.
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,
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.
If the Australian Government decides to interview you in
regard to your application, then you will be provided with
more information on the values that Australians share
and their way of life. Every applicant, aged 18 years or
over, will then be asked to sign a statement that they
understand and respect the values of Australian society
and will obey the laws of Australia. This includes
acknowledging what would be required if they later
applied for Australian citizenship.
© COMMONWEALTH OF A
Form
842
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.
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.
842 (Design date 07/13) - Page 1
| Page 2 |
© COMMONWEALTH OF A
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.
‘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 irregular maritime
arrival.
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.
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 of Immigration and Citizenship (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.
842 (Design date 07/13) - Page 2
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 programs. 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 O 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 O, please provide a written explanation
why the documents are not available.
Under no circumstances should you submit false
documents.
USTRALIA, 2013
| Page 3 |
© COMMONWEALTH OF A
Where can you lodge this application?
Generally, your application for a Class XB visa should be lodged
at the nearest office of the department (eg. an Australian
processing centre; or an Embassy, High Commission, Consulate
or Consulate-General overseas).
Note: Applicants wishing to be considered for a Class XB visa
under either the Global Special Humanitarian Program (subclass
202), or the ‘split family’ provisions for immediate family
members, must lodge this form in accordance with the
addresses specified below:
• For applicants residing in the Middle East*, Afghanistan or
Pakistan, applications must be lodged at the following
address:
Victoria Offshore 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.)
• For applicants residing in any other country apart from those
listed above, applications must be lodged at the following
address:
NSW Offshore 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.immi.gov.au
Is there an application or processing charge?
No – there is no charge to lodge this application.
Is there a charge for the form?
No – forms 681 and 842 are free and may be obtained from any
office of the department in Australia and overseas or are
available free-of-charge from the department’s website
www.immi.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 health
examinations for all humanitarian visa applicants. All visa
subclasses except Global Special Humanitarian (subclass 202)
visa holders will also have their travel costs paid by the Australian
Government.
About the information you give
The department is authorised to collect information provided
on this form under Part 2 of the Migration Act 1958 ‘Control of
Arrival and Presence of Non-citizens’. The information provided
will be used for assessing your eligibility for a Refugee and
Humanitarian (Class XB) visa and for other purposes relating
to the administration of the Migration Act.
Information provided might also be disclosed to other agencies
authorised to receive information in relation to foreign affairs,
adoption, border control, business skills, citizenship, education,
health, law enforcement, taxation, pensions and benefits, service
provision to refugees and eligible humanitarian entrants and
their proposers, review of decisions and registration of
migration agents.
The information form 993i Safeguarding your personal
information, available from offices of the department in
Australia, or from the place where you obtained this form, gives
details about the agencies to which your information might be
disclosed.
The department may also provide some information in your
application to the office of the UNHCR.
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.
The department is authorised under the Migration Act, in
certain circumstances, to collect a range of personal identifiers
including a facial image, fingerprints and a signature, from non-
citizens, including from visa applicants. The department requires
personal identifiers to assist in assessing your identity. The
department is authorised to disclose your personal identifiers
and information relating to your name and other relevant
biographical data to a number of agencies including law
enforcement and health agencies, and other agencies who may
need to check your identity with this department. Where the
department obtains personal identifiers, they will become part
of your official record with the department.
USTRALIA, 2013
842 (Design date 07/13) - Page 3
| Page 4 |
© COMMONWEALTH OF A
The department is involved in international information
exchanges with a number of countries, including the United
Kingdom, the United States of America, Canada and New
Zealand. These international information exchanges may involve
the sharing of personal identifiers, including facial images and
fingerprint data, collected by immigration agencies such as this
department. If, as a result of this sharing between countries,
there is a match with your personal identifiers, the department
will disclose your biographical data, copies of travel and other
identity documents or information from such documents, your
immigration status and immigration history (which may include
any immigration abuse and offences) and any criminal history
information relevant to immigration purposes. The purpose of
such disclosure would be to help confirm your identity and
determine if you have presented to the department and the
other agency under the same identity and with similar claims.
The department will only disclose this information if none of
these countries is a country of claimed persecution and only if
the department is reasonably satisfied that this information will
not be disclosed to your country of claimed persecution or
substantial discrimination.
For more detailed information you should read form 1243i Your
Personal Identifying Information, which is available form the
department’s website www.immi.gov.au/allforms/ or from
any office of the department.
Review rights
If your application is refused, it is not possible to obtain a review
of the decision by the Migration Review Tribunal or the Refugee
Review Tribunal.
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.
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.
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.
842 (Design date 07/13) - Page 4
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.
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.immi.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
Pa
r
t
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.immi.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.
USTRALIA, 2013
| Page 5 |
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 a proposal form 681 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 e-mail 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 or form 681 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.immi.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, 2013
842 (Design date 07/13) - Page 5
| Page 6 |
This page is intentionally blank
| Page 7 |
1
2
For your relationship status (other than ‘never married or been in a
de facto relationship’), give the following details:
Do you currently have more than one partner (other than any partner
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
‘Status in this countr
other form of a relationship (eg. boyfriend/girlfriend)?
PR
TR
C
S
V
R
I
A
O
Application for an
Offshore Humanitarian visa
Refugee and Humanitarian (Class XB) visa
Please use a pen, and write neatly in English using BLOCK LETTERS.
Tick where applicable
Part A – Summary of people included in this application
• Only include members of your family who are dependent on you or your partner.
• A dependant is a person who is wholly or substantially dependent on you or your partner for financial, psychological
or physical support.
• The term ‘partner’ in this form, means your spouse or de facto partner (including same-sex partners).
• Non-dependent family members (eg. adult independent children, married children or children over 18 who have their
own income) should complete their own application form. However you should still list any non-dependent children
at 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.
How many people are included in this application?
Relationship status
Married legally
Engaged
Give details of the main applicant
Married by
De facto
Family name
A
1
tradition/custom
Married religiously
Separated
Given names
Divorced
Name in own
DAY
MONTH
language or
ethnic script
Date this happened
Sex
Male
Female
Place this happened
DAY
MONTH
YEAR
Your previous name (if applicable)
Date of birth
Place of birth Town/city
Country
included in this visa application)?
Citizenship
No
If stateless, write your previous countr y of citizenship
Yes
Please provide details
Current country of residence
Date you arrived in
DAY
MONTH
YEAR
this country
Select
Status in this country
See below for codes to be used
y’ codes
= Citizen
No
= Permanent resident
= Temporary resident
Yes
Please provide details
= Student
= Visitor/Tourist
= Refugee
= Illegal resident
= Asylum/protection applicant
= Other – give details on a
separate page
© COMMONWEALTH OF AUSTRALIA, 2013
Form
842
PHOTOGRAPHS
Please attach eight (8) recent
passport sized photographs
of yourself
AND
all members of your family
unit included in this
application
Note: Clearly write the name
of the person on the back of
each photograph
Widowed
Never married or
been in a de facto
relationship
YEAR
842 (Design date 07/13) - Page 7
| Page 8 |
A
y of citizenship
© COMMONWEALTH OF A
3 Give details of all other people included in this application
1. Family name
Given names
Name in own
language or
ethnic script
Sex
Male
Female
DAY
MONTH
YEAR
Date of birth
Place of birth Town/city
Country
Citizenship
If stateless, write your previous countr
Relationship status
Married legally
Engaged
Widowed
Married by
De facto
Never married or
tradition/custom
Married religiously
Separated
been in a de facto
relationship
Divorced
Relationship to
main applicant
Is this person biologically related to the main applicant?
No
Explain how they are related to the main applicant
Yes
Describe the precise biological relationship
842 (Design date 07/13) - Page 8
2
2. Family name
A3
Given names
Name in own
language or
ethnic script
Sex
Male
Female
DAY
MONTH
YEAR
Date of birth
Place of birth Town/city
Country
Citizenship
If stateless, write your previous countr y of citizenship
Relationship status
Married legally
Engaged
Widowed
Married by
De facto
Never married or
tradition/custom
Married religiously
Separated
been in a de facto
relationship
Divorced
Relationship to
main applicant
Is this person biologically related to the main applicant?
No
Explain how they are related to the main applicant
Yes
Describe the precise biological relationship
USTRALIA, 2013
| Page 9 |
A
y of citizenship
© COMMONWEALTH OF A
3. Family name
Given names
Name in own
language or
ethnic script
Sex
Male
Female
DAY
MONTH
YEAR
Date of birth
Place of birth Town/city
Country
Citizenship
If stateless, write your previous countr
Relationship status
Married legally
Engaged
Widowed
Married by
De facto
Never married or
tradition/custom
Married religiously
Separated
been in a de facto
relationship
Divorced
Relationship to
main applicant
Is this person biologically related to the main applicant?
No
Explain how they are related to the main applicant
Yes
Describe the precise biological relationship
4
4. Family name
A5
Given names
Name in own
language or
ethnic script
Sex
Male
Female
DAY
MONTH
YEAR
Date of birth
Place of birth Town/city
Country
Citizenship
If stateless, write your previous countr y of citizenship
Relationship status
Married legally
Engaged
Widowed
Married by
De facto
Never married or
tradition/custom
Married religiously
Separated
been in a de facto
relationship
Divorced
Relationship to
main applicant
Is this person biologically related to the main applicant?
No
Explain how they are related to the main applicant
Yes
Describe the precise biological relationship
USTRALIA, 2013
842 (Design date 07/13) - Page 9
| Page 10 |
A
y of citizenship
© COMMONWEALTH OF A
5. Family name
Given names
Name in own
language or
ethnic script
Sex
Male
Female
DAY
MONTH
YEAR
Date of birth
Place of birth Town/city
Country
Citizenship
If stateless, write your previous countr
Relationship status
Married legally
Engaged
Widowed
Married by
De facto
Never married or
tradition/custom
Married religiously
Separated
been in a de facto
relationship
Divorced
Relationship to
main applicant
Is this person biologically related to the main applicant?
No
Explain how they are related to the main applicant
Yes
Describe the precise biological relationship
842 (Design date 07/13) - Page 10
6
6. Family name
A7
Given names
Name in own
language or
ethnic script
Sex
Male
Female
DAY
MONTH
YEAR
Date of birth
Place of birth Town/city
Country
Citizenship
If stateless, write your previous countr y of citizenship
Relationship status
Married legally
Engaged
Widowed
Married by
De facto
Never married or
tradition/custom
Married religiously
Separated
been in a de facto
relationship
Divorced
Relationship to
main applicant
Is this person biologically related to the main applicant?
No
Explain how they are related to the main applicant
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)
USTRALIA, 2013
| Page 11 |
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, e-mail
Note: You must tell us if your address changes after you lodge this form
or other electronic means?
No
Yes
Give details
COUNTRY CODE
AREA CODE
NUMBER
POSTAL CODE
Fax number
(
) (
)
6 Address where we should write to you about this application if different
E-mail address
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.
POSTAL CODE
Your contact telephone numbers (if available)
COUNTRY CODE
AREA CODE
NUMBER
Telephone number
(
) (
)
Mobile/cell
(
) (
)
© COMMONWEALTH OF AUSTRALIA, 2013
842 (Design date 07/13) - Page 11
| Page 12 |
Part D – Family background
Have you or any other person included in this visa application
previously been legally married, in a de facto relationship or in a
y/traditional/religious marriage that is not legally recognised?
Give details of each person below
If you need more space, please attach a separate page with the details
842 (Design date 07/13) - Page 12
USTRALIA, 2013
8
customar
No
Yes
1. Family name
Given names
Previous partner’s
full name
Dates of
relationship
(DAY/MONTH/YEAR)
How did the
relationship end?
Names of all
children from
this previous
relationship
2. Family name
Given names
Previous partner’s
full name
Dates of
relationship
(DAY/MONTH/YEAR)
How did the
relationship end?
Names of all
children from
this previous
relationship
FROM
TO
9
FROM
TO
© COMMONWEALTH OF A
3. Family name
Given names
Previous partner’s
full name
Dates of
FROM
relationship
(DAY/MONTH/YEAR)
TO
How did the
relationship end?
Names of all
children from
this previous
relationship
Attach a certified copy of previous marriage/divorce documents
or death certificate (if applicable/available)
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?
No
Yes
Attach a certified copy of the
custody documents (if available)
Note: Where custody documents are not provided or
assessed as unsatisfactory, the former partner will need to
provide evidence that he/she consents to any children of
that relationship entering Australia.
| Page 13 |
Are there any children included in this application who are
biological children of either you (the main applicant) or your partner?
If you need more space, please attach a separate page with the details
Has this child been adopted (formally, customarily or traditionally)
For each adopted child, attach a certified copy of the adoption
papers (if available) or attach a statement which explains the
circumstances of the adoption
Has this child been adopted (formally, customarily or traditionally)
10
No
Yes
Give details of each child
1. 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)
by the main applicant and/or partner?
No
DAY
Yes
Date custody commenced
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)
by the main applicant and/or partner?
No
DAY
Yes
Date custody commenced
not the
3.
MONTH
YEAR
MONTH
YEAR
© COMMONWEALTH OF AUSTRALIA, 2013
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
DAY
MONTH
YEAR
Yes
Date custody commenced
842 (Design date 07/13) - Page 13
| Page 14 |
Do you have a husband, wife, de facto partner or any dependants who
Is any person included in this application physically separated from
normally live with you but who are
you (eg. missing or living at a separate address/location)?
A dependant is a person who is wholly or substantially dependent on
you or your partner for financial, psychological or physical support.
If you need more space, please attach a separate page with the details
If you need more space, please attach a separate page with the details
842 (Design date 07/13) - Page 14
USTRALIA, 2013
11
No
Yes
1.
2.
3.
12
not included in this application?
Give details and explain why they do not intend
to migrate with you as part of this visa
application
Family name
Given names
DAY
MONTH
YEAR
Date of birth
Relationship
to you
Reason they are not applying with you
Family name
Given names
DAY
MONTH
YEAR
Date of birth
Relationship
to you
Reason they are not applying with you
Family name
Given names
DAY
MONTH
YEAR
Date of birth
Relationship
to you
Reason they are not applying with you
© COMMONWEALTH OF A
No
Yes
1.
2.
3.
Give details and explain when and where you
were last in contact with them
Family name
Given names
Date of birth (DAY/MONTH/YEAR)
Relationship
to you
Last contact
(when, where
and how you
were separated)
Full residential
address
(if known)
POSTAL CODE
Family name
Given names
Date of birth (DAY/MONTH/YEAR)
Relationship
to you
Last contact
(when, where
and how you
were separated)
Full residential
address
(if known)
POSTAL CODE
Family name
Given names
Date of birth (DAY/MONTH/YEAR)
Relationship
to you
Last contact
(when, where
and how you
were separated)
Full residential
address
(if known)
POSTAL CODE
| Page 15 |
parents, brothers and sisters and non-dependent children. You must include half, step and adopted relatives.
If any person listed below is not biologically rela
ted to you, you must clearly indicate this.
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 ‘Countr
Relationship
(all children who are not included as dependants in this application)
If you need more space, please attach a separate page listing further names
13 Relatives of MAIN APPLICANT
Give details of ALL YOUR
Note: You must list ALL
Name
Your parents
Mother’s maiden name
Your brothers and sisters
Your non-dependent children
Sex
Date of birth
M/F DAY
MONTH YEAR
status
(use codes
on right)
y where they are now living’ column.
Relationship
Status in
‘Relationship status’ codes
to main
country of
N = Never married or been in a
Place and countr
y of birth
applicant
(use codes
on right)
Countr
are now living
y where they
residence
(use codes
on right)
M
=
de facto relationship
Married legally
E = Engaged to be married
S = Separated
F = In a de facto relationship
D = Divorced
W = Widowed
MT = Married by tradition/custom
MR = Married religiously
‘Relationship to main applicant’
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’
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
© COMMONWEALTH OF AUSTRALIA, 2013
842 (Design date 07/13) - Page 15
| Page 16 |
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
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 ‘Countr
y where they are now living’ column.
y of birth
(all children who are not included as dependants in this application)
If you need more space, please attach a separate page listing further names
USTRALIA, 2013
14 Relatives of main applicant’s PARTNER
Give details of ALL YOUR PARTNER’s
Note: You must list ALL YOUR PARTNER’s
Name
Your partner’s parents
Your partner’s mother’s maiden name
Your partner’s brothers and sisters
Your partner’s non-dependent children
842 (Design date 07/13) - Page 16
Sex
Date of birth
M/F DAY
MONTH YEAR
Relationship
status
(use codes
on right)
Place and countr
© COMMONWEALTH OF A
must clearly indicate this.
Relationship
to main
Status in
applicant’s
country of
partner
Country where they
residence
(use codes
on right)
are now living
(use codes
on right)
‘Relationship status’ codes
N = Never married or been in a
de facto relationship
M = Married legally
E = Engaged to be married
S = Separated
F = In a de facto relationship
D = Divorced
W = Widowed
MT = Married by tradition/custom
MR = Married religiously
‘Relationship to main
applicant’s partner’ 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’
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
| Page 17 |
Where was the application lodged?
Where was the application lodged?
Refugee and Special Humanitarian Proposal
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
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 (If all persons included
Date of
application
in this application, write ‘ALL’)
DAY
MONTH YEAR
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
Family and given name
application
DAY
MONTH YEAR
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) for entry to
Australia by a person or organisation in Australia?
No
Yes
Give details of your proposer
Family name
Given names
OR
Organisation name
Contact person
Relationship of the
proposer to you
Address of the proposer
POSTCODE
Telephone number
(AREA CODE )
Attach a completed form 681
application (there is no charge for lodging or processing form 681)
website www.immi.gov.au
© COMMONWEALTH OF AUSTRALIA, 2013
File number
Application approved?
(if known)
No Yes Not decided
File number
Type of visa application
(if known)
(if known)
to this
842 (Design date 07/13) - Page 17
| Page 18 |
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 chil d
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.immi.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 07/13) - Page 18
© COMMONWEALTH OF AUSTRALIA, 2013
| Page 19 |
Do any people included in this application have any other relatives residing in Australia?
Details of the relative in Australia
Details of the person in this application they are related to
Date of birth
If you need more space, please attach a separate page with the details
Do any people included in this application have any
other past or present links to Australia?
‘Resident status in Australia’ codes
PR
TR
19
No
Yes
1.
2.
3.
4.
5.
20
No
Yes
Give details
Name
DAY
Indicate the types of links and give details
Education
Employment
Business
Friend
Other
MONTH
YEAR
Resident
status in
Australia
Address
Given names
(use codes
below)
© COMMONWEALTH OF AUSTRALIA, 2013
C
S
V
I
U
O
Relationship to applicant
= Citizen
= Permanent resident
= Temporary resident
= Student
= Visitor/Tourist
= Illegal resident
= Unlawful non-citizen
= Other – give details on a
separate page
842 (Design date 07/13) - Page 19
| Page 20 |
21
‘Type of document’ codes
UN
NIC
842 (Design date 07/13) - Page 20
USTRALIA, 2013
P
A
CI
S
Part F – Background information
Give details of any valid travel documents (eg. passports) or identity
cards/documents held by all people included in this application
Note: If you do not have any documents, please explain why – do not
obtain fraudulent documents.
A1
Main applicant
Do you 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)
Other applicants
A2 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)
= Passport
= UN Convention travel document or Titre de voyage
= Alien/Asylum Registration Card
= Certificate or document of identity
= Seafarer identity document
= National identity card
© COMMONWEALTH OF A
A3 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)
A4 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)
A5 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)
| Page 21 |
‘Type of document’ codes
UN
NIC
P
A
CI
S
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 passport
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
= Passport
= UN Convention travel document or Titre de voyage
= Alien/Asylum Registration Card
= Certificate or document of identity
= Seafarer identity document
= National identity card
© COMMONWEALTH OF AUSTRALIA, 2013
842 (Design date 07/13) - Page 21
| Page 22 |
Which countr
Date you started to live
at this address
Given names of people included in this application
who live at this address (if all, write ‘ALL’)
Period at this address
Given names of people included in this application
who lived at this address (if all, write ‘ALL’)
Attach certified copies of any visas/residence permits held by your family
© COMMONWEALTH OF A
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
(If all persons included in this application,
Date of application
write ‘ALL’)
DAY
MONTH YEAR
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
Address where you are living now
Town
Country
Previous addresses
1.
Town
Country
2.
Town
Country
3.
Town
Country
4.
Town
Country
5.
Town
Country
842 (Design date 07/13) - Page 22
y?
DAY
MONTH
FROM MONTH
TO
MONTH
FROM MONTH
TO
MONTH
FROM MONTH
TO
MONTH
FROM MONTH
TO
MONTH
FROM MONTH
TO
MONTH
USTRALIA, 2013
YEAR
YEAR
YEAR
YEAR
YEAR
YEAR
YEAR
YEAR
YEAR
YEAR
YEAR
Type of application
(eg. refugee resettlement,
migration, asylum etc.)
Application approved?
No Yes Not decided
| Page 23 |
Part G – Humanitarian claims
• It is important for all applicants (including those proposed by a person or organisation in Australia) to provide all details of your humanitarian claims.
An assessment of your humanitarian claims will include consideration against the following four factors:
– the degree of persecution or discrimination to which you are subject in your home country, and
– the extent of your connection with Australia, and
– whether or not there is any suitable country available, other than Australia, that can provide for your settlement and protection from discrimination, and
– the capacity of the Australian community to provide for the permanent settlement of persons such as you in Australia.
So that the decision-maker can give full consideration to your application you should include as much information against these factors as possible.
• 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
Program.
• 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
Given names
Ethnic group or clan
Religion (if any)
Membership of political party/group
(if any)
A1
Main applicant
Other applicants
A2
A3
A4
A5
A6
A7
If you need more space, please attach a separate page with the details
© COMMONWEALTH OF AUSTRALIA, 2013
842 (Design date 07/13) - Page 23
| Page 24 |
25 What is the name of the country you have a
fear of returning to?
26 When did you leave the country you
DAY
MONTH
YEAR
fear returning to?
27 Why did you leave the country you fear returning to?
Your answer should pay special attention to what happened to you, not the general situation in that countr y.
If you need more space, please attach a separate page with details
842 (Design date 07/13) - Page 24
© COMMONWEALTH OF AUSTRALIA, 2013
| Page 25 |
28
29
30
How did you leave the country you fear returning to?
Legally
Give details of your exit permit
Illegally
Describe how you arranged to leave illegally
What do you believe may happen to you, or the people included in your application, if you were to return to that country?
You should give full details of what you think ma y happen to you and reasons why that would happen
If you need more space, please attach a separate page with details
Who do you think may harm or mistreat you if you go back to that country?
If you need more space, please attach a separate page with details
© COMMONWEALTH OF AUSTRALIA, 2013
842 (Design date 07/13) - Page 25
| Page 26 |
842 (Design date 07/13) - Page 26
31
32
33
34
Do you think the authorities of that country can and will protect you if you return to that country?
No
Please explain why
Yes
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
Dates
From
To
Country
DAY
MONTH
YEAR
DAY
MONTH
YEAR
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)
Has any person included in this application served in a military
organisation (army/airforce/navy) or in a paramilitary organisation?
No
Yes
Give details
Given names
Country served
Name of military/paramilitary organisation
Rank in this organisation
Dates of membership of this organisation
FROM
TO
FROM
TO
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
© COMMONWEALTH OF AUSTRALIA, 2013
| Page 27 |
view we will advise you if you are required to provide your own interpreter
USTRALIA, 2013
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
Who ran the
Name of camp/centre
Location
camp/centre?
1.
2.
3.
4.
5.
6.
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)?
If you are selected for an inter
© COMMONWEALTH OF A
Dates lived there
DAY
MONTH
YEAR
FROM
TO
FROM
TO
FROM
TO
FROM
TO
FROM
TO
FROM
TO
Given names of people included in this
application who lived there
(if all, write ‘ALL’)
842 (Design date 07/13) - Page 27
| Page 28 |
Part H – Employment histor
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
For each person, start with the latest period of employment and work backwards
Dates of employment
842 (Design date 07/13) - Page 28
37
A1
FROM
TO
FROM
TO
FROM
TO
FROM
TO
FROM
TO
FROM
TO
A2
FROM
TO
FROM
TO
FROM
TO
FROM
TO
FROM
TO
A3
FROM
TO
FROM
TO
FROM
TO
A4
FROM
TO
FROM
TO
FROM
TO
y
unemployment
Name of employer
Location of employer
Type of business
Occupation and main duties
DAY
MONTH YEAR
Main applicant
Other applicants
Name
Name
Name
© COMMONWEALTH OF AUSTRALIA, 2013
| Page 29 |
(Question 37 continued)
Dates of employment
If you need more space, please attach a separate page with the details
A5
FROM
TO
FROM
TO
FROM
TO
FROM
TO
A6
FROM
TO
FROM
TO
FROM
TO
FROM
TO
A7
FROM
TO
FROM
TO
FROM
TO
FROM
TO
FROM
TO
FROM
TO
FROM
TO
FROM
TO
FROM
TO
FROM
TO
Name of employer
Location of employer
Type of business
Occupation and main duties
DAY
MONTH YEAR
Name
Name
Name
Name
Name
© COMMONWEALTH OF AUSTRALIA, 2013
842 (Design date 07/13) - Page 29
| Page 30 |
How well this person
speaks English
Highest educational qualification
obtained (eg. school certificate,
electrician certificate, BA, PhD)
English language codes
Ver
Well (eg. can speak English well enough to deal with basic social and work situations)
Not well (eg. can speak only a little English)
Not at all
842 (Design date 07/13) - Page 30
38
39
1 =
2 =
3 =
4 =
Part I – Language and education
For EACH person included in this application, give details of their language
Given names
Main language spoken
A1
Main applicant
Other applicants
A2
A3
A4
A5
A6
A7
If you need more space, please attach a separate page with the details
For EACH person included in this application, give details of their education
Primary school
Secondary school
Given names
DAY
MONTH YEAR
DAY
MONTH YEAR
A1
Main applicant
FROM
FROM
TO
TO
Other applicants
A2
FROM
FROM
TO
TO
A3
FROM
FROM
TO
TO
A4
FROM
FROM
TO
TO
A5
FROM
FROM
TO
TO
A6
FROM
FROM
TO
TO
A7
FROM
FROM
TO
TO
FROM
FROM
TO
TO
FROM
FROM
TO
TO
If you need more space, please attach a separate page with the details
y well (eg. can speak English with little hesitation and few errors in most situations)
© COMMONWEALTH OF AUSTRALIA, 2013
Other languages spoken
Post-secondary education
DAY
MONTH YEAR
FROM
TO
FROM
TO
FROM
TO
FROM
TO
FROM
TO
FROM
TO
FROM
TO
FROM
TO
FROM
TO
Select
(insert code
from below)
| Page 31 |
Have you, or any other person included in this application, undertaken a
health examination for an Australian visa in the last 12 months?
Give details (including HAP ID if available)
to any of the above questions, provide all 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
If you need more space, please attach a separate page with the details
© COMMONWEALTH OF A
Part J – Health
40
No
Yes
Part K – Character
41 Has any person included in this application ever:
• been convicted of a crime or offence
in any country?
• been charged with any offence that is
currently awaiting legal action?
• been found guilty or acquitted of any criminal
or other offence on the grounds of mental
illness, insanity or unsoundness of mind?
• been deported from any country?
• left any country voluntarily prior to the
execution of a deportation order?
• been excluded from or required to leave
any country?
• been involved in any activities that would
represent a risk to Australian national security?
• committed or been involved in the
commission of war crimes or crimes
against humanity or human rights?
• been involved in any activity, or been
convicted of any offence, relating to the
illegal movement of people to any
country (including Australia)?
• had any outstanding debts to the
Australian Government or any public
authority in Australia?
• served in a military force or state
sponsored/private militia, undergone any
military/paramilitary training, or been trained in
weapons/explosives use (however described)?
If you answered ‘Yes’
of imprisonment or other detention.
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Part L – Assistance with this form
42 Did you receive assistance in completing this form?
No
Go to Part M
Yes
Please give details of the person who assisted you
Title: Mr
Mrs
Miss
Ms
Other
Family name
Given names
Address
POSTCODE
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
Part M – Options for receiving written
communications
46 All written communications about this application should be sent to:
(Tick one box only)
Myself
OR
Proposer
All written communications will be sent to the
address of the proposer provided in this form.
OR
Authorised
recipient
You should complete form 956A
or withdrawal of an authorised recipient
Appointment
OR
Migration agent
Your migration agent/exempt person should
complete form 956 Advice by a migration
OR
agent/exempt person of providing
Exempt person
immigration assistance
USTRALIA, 2013
842 (Design date 07/13) - Page 31
| Page 32 |
person has made an incorrect statement in relation to their applicat
your application to enter Australia may be refused. If you
information, such as an offence, your visa will be lia
y to Australia. In the event that you have already entered Australia your visa will be liable to cancell
– If your circumstances change after you lodge this application (eg. you change your address, marr
tion. If your application is supported by a proposal form 681
, and your proposer’s circumstances change after you have lodged this application, you should also notify the office where you
© COMMONWEALTH OF A
Part N – Declaration and consent
Warning: The Migration Act contains a power to cancel a visa if a
determined that you have concealed information, such as an offence,
granted a visa and it is subsequently discovered that you have concealed
you may be refused entr
you may be detained and removed from Australia.
47 This declaration and consent must be signed by you (the main applicant)
and ALL persons aged 18 or over included in this application.
• I declare the information I have supplied on and with this form is
complete, correct and up-to-date in ever y detail.
• I declare that I did not marr y or enter a de facto relationship to
become eligible for entr y to Australia.
• I understand that if I have given false or misleading information, my
application may be refused, or, if a visa has been granted, the visa
may be cancelled and I could be removed from Australia.
• I understand that if I am granted a visa, any person not included in
this application will not have automatic right of entr y to Australia by
way of this application.
• I undertake to inform the Australian Government of any material
changes to my circumstances while my application is being
considered, or before I am immigration cleared.
(
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
necessar y to determine my eligibility for entr y to Australia, and to
use any information supplied in this application for that purpose.
• I understand that unless my qualifications have already been
recognised by an Australian assessing authority before my departure,
they may not be recognised after my arrival.
• I understand that it is my personal responsibility to assess my own
employment prospects in Australia and acknowledge that labour
market conditions there can var y significantly from time to time and
between regions.
• I understand that grant of a visa provides no guarantee of
employment once in Australia.
For offshore applicants who are required to provide their fingerprints
and facial image:
• I understand that my fingerprints and facial image and my
biographical information held by the Department of Immigration and
Citizenship may be given to Australian law enforcement agencies to
help identify me, to help determine my eligibility for grant of the visa
I have applied for, and for law enforcement purposes.
• I consent to:
– Australian law enforcement agencies disclosing my biometric,
biographical and criminal record information to the Department
of Immigration and Citizenship for any of the purposes outlined
above; and
– the Department of Immigration and Citizenship using the
information obtained for the purposes of the Migration Act 1958
or the Citizenship Act 2007 .
Important
a baby), you must notify the office where you lodge this applica
proposal
842 (Design date 07/13) - Page 32
ion. If it is
have already been
ble to cancellation and
ation and, if cancelled,
WARNING: Giving false or misleading information is a serious offence.
Signature or mark
of applicant
Date (DAY/MONTH/YEAR)
Signature or mark
of partner
(if applicable)
Date (DAY/MONTH/YEAR)
Signatures of persons aged 18 years or over who are
included in this application (if applicable)
Signature or mark
Date (DAY/MONTH/YEAR)
Signature or mark
Date (DAY/MONTH/YEAR)
Signature or mark
Date (DAY/MONTH/YEAR)
Signature or mark
Date (DAY/MONTH/YEAR)
Signature or mark
Date (DAY/MONTH/YEAR)
Signature or mark
Date (DAY/MONTH/YEAR)
We strongly advise that you keep a copy of your application and
all attachments for your records.
y or become engaged to be married, or have
Refugee and special humanitarian
lodge this application.
USTRALIA, 2013
| Page 33 |
Part O – Document checklist
This checklist is provided to help you submit a complete, decision-ready
application. If you do not have any of the requested documents (originals
or certified* copies) listed below, please provide an explanation as to
why you no longer have these documents.
UNDER NO CIRCUMSTANCES SHOULD YOU SUBMIT FALSE
DOCUMENTS
Have you attached the following documents?
USTRALIA, 2013
48
Question
Q2 & 3
Q4
Q8
Q9
Q10
Q17
Q18
Q21
Q23
Document
Attached?
Eight (8) recent passport size photographs
of each person included in your application,
with the full name of the person
written on the back of each
photograph
Evidence of the identity of each person
included in this application (eg. certified*
copies of birth certificates, marriage
certificates, passport, national identity
card etc.), if available
Evidence of registration with any
international organisation dealing with
refugees (eg. UNHCR), if applicable
Certified* copies of previous marriage/divorce
papers, or death certificates (if applicable)
Certified* copies of child custody papers
(if applicable)
Certified* copies of adoption papers or a
written statement which explains the
circumstances of adoption (if applicable)
If your entry to Australia is being proposed
by a person or organisation in Australia,
attach a fully completed form 681
completed by your proposer
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
Certified* copies of travel documents and/or
identity cards held by any person included
in this application (if available)
OR
A statement explaining why you have no
travel/identity documents
Certified* copies of any visas/residence
permits held by any person included in this
application (if available)
© COMMONWEALTH OF A
Question
Document
Attached?
Q27
A detailed written statement (in English),
clearly explaining the reasons why you left
the country you fear returning to
OR
If you have been referred for resettlement
by the UNHCR, a full copy of your UNHCR
Resettlement Registration Form (RRF)
Q33
Certified* copies of any discharge papers
(if available)
• If you have attached additional pages with answers, each page must
be marked with the question number it refers to, and signed
and dated by each person aged 18 years or over who is included in
this application.
• Please ensure you, your partner and persons aged 18 years or over
who are included in this application have signed the Declaration at
Part N.
• If you do not provide all the necessary documents, or you have not
provided an adequate explanation why you cannot provide these
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 lodging this application.
• You must lodge your Class XB visa application at the relevant office
of the department responsible for visa applications from your country
of residence. To find out which office of the department you need to
lodge your application with, refer to the department’s website at
www.immi.gov.au
Note: Certain applicants must lodge their application in Australia (see
‘Where can you lodge this application?’ on page 3).
*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 Statutor y 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 07/13) - Page 33