Form
1221
Please use a pen, and write neatly in English using BLOCK LETTERS. Tick where applicable
Integrity of application
The Department of Immigration and Citizenship (the department) is committed to maintaining the integrity of the visa and citizenship programs. Please be aware that if you provide us with fraudulent documents or claims, this may result in processing delays and possibly your application being refused.
Other names you are, or have been, known by (including name at birth, previous married names, aliases)
Name in your own language or script (if applicable). Please write Chinese names in Chinese Commercial Code Numbers
DAY
MONTH
YEAR
4 5
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.
6 7
Sex
Male
Female
Relationship status Married Engaged De facto Separated Divorced Widowed Never married or been in a de facto relationship
DAY
MONTH
YEAR
Your current residential address (a post office box address is not acceptable as a residential address)
POSTCODE
Date of issue Date of expiry Issuing authority/ Place of issue as shown in your passport
POSTCODE
POSTCODE
( (
) )
Are you applying for: permanent residency a further temporary stay protection
17 Visa subclass you are applying for 13 Do you agree to the department communicating with you by fax, e-mail
or other electronic means? No Yes Fax number E-mail address Give details
COUNTRY CODE ( ) ( AREA CODE ) NUMBER
From
to
21 Give details of each place you intend to stay in Australia, including the
length and purpose of each stay 1. Place you intend to stay Purpose of stay
to
DAY
MONTH
YEAR
DAY
MONTH
YEAR
Employers address
to
POSTCODE
Purpose of stay
DAY
MONTH
YEAR
DAY
MONTH
YEAR
to
Duties
DAY
MONTH
YEAR
DAY
MONTH
YEAR
to
DAY
MONTH
YEAR
DAY
MONTH
YEAR
to
Employers address
POSTCODE
Purpose of stay
DAY
MONTH
YEAR
DAY
MONTH
YEAR
From
to
Duties
to
POSTCODE POSTCODE
Telephone number
COUNTRY CODE ( ) ( AREA CODE ) NUMBER
Yes
DAY
MONTH
YEAR
DAY
MONTH
YEAR
to
Year of award
Year of award
Year of award
Qualification
26 List all titles and describe any previous academic or research papers
you have had published Main subjects or duties
Year of award
28 Date of birth of
personal contact
DAY
MONTH
YEAR
Employers address
POSTCODE
POSTCODE
( (
) )
Employers address
35 Will your intended business activity in Australia require you to visit more
than one place of work?
POSTCODE
No Yes List the name and location of institutions you will visit during your stay in Australia, the type of business each institution does and the name of your contact at each institution
Part J Student/Academic/Researcher/Fellows
40 Give details of your thesis topic and research to be undertaken
Name of employer
Employers address
POSTCODE
Name of employer
Employers address
POSTCODE
Part L Declaration
WARNING: Giving false or misleading information is a serious offence.
44 I declare that:
the information I have supplied in this application is complete, correct and up-to-date in every detail; and I have read and understood the information supplied to me.
Signature of applicant
DAY MONTH YEAR
43 Are there any other details you would like taken into consideration?
Question number Additional information
Date
We strongly advise that you keep a copy of this form and all attachments for your records.