PITCAIRN SETTLEMENT APPLICATION FORM

SECTION 1. TYPE OF APPLICATION

1. On what basis are you applying for settlement on Pitcairn? (Tick one)

As the spouse of someone settled, or applying now to settle, on Pitcairn

As the civil partner of someone settled, or applying now to settle, on Pitcairn

As the fiancé/fiancée/proposed civil partner of someone settled, or applying now to settle, on Pitcairn

As the unmarried partner of someone settled, or applying now to settle, on Pitcairn (de facto)

As the child of someone settled, or applying now to settle, on Pitcairn

As the adopted child of someone settled, or applying now to settle, on Pitcairn

As an elderly dependant of someone settled, or applying now to settle, on Pitcairn

Other (please give details)

Approved GPI Settlement Application Form Reviewed 03/18

SECTION 2. ABOUT YOU
Please write clearly.
You must also send a scanned copy of your passport photo page with this application
2.1 What is your full name, as it appears in your passport? Please underline your family name:

2.2 Any other names you have been known by?

2.3 Date of birth:

2.4 Place of birth;

2.5 Nationality:

2.6 Sex: Male Female

2.7a Current marital status: Single Married Divorced Widowed Separated Civil Partnership De facto
(see also section 3)

2.8 Your passport number:

2.9 Dates of issue and expiry

2.10 Place of issue

2.11 What is your father’s full name?

2.12 What is your mother’s full name?

2.13 Your permanent home address

2.14 Your correspondence address, if different from 2.13

2.15 Your home telephone number

2.16 Any home fax number

2.17 Your personal e-mail address

2.18 Your mobile phone number:

2.19 When and how do you wish to travel to Pitcairn? (Please give a date) ________________

Approved GPI Settlement Application Form Reviewed 03/18

SECTION 3. YOUR FAMILY
3.1 Have you ever been married, in a relationship like a marriage, or a civil partnership? Yes No

If you have answered yes to question 3.1, please give details, including dates, below. If you have been
widowed, divorced, had a dissolved civil partnership or are a surviving civil partner, please indicate here.

3.2 If you are married, in a relationship like a marriage, or in a civil partnership, to/with someone other than
your sponsor, what is your partner’s name?

3.3 What is his/her date of birth?

3.4 Where is he/she now?

3.5 Is he/she travelling with you? Yes, on my passport Yes, on his/her own passport No

Children
3.6 Do you have any children from your marriage or relationship, or from previous relationships?
Yes No

If you have answered yes to question 3.6 please give their details below. Otherwise go to question 3.8.
Please continue on a separate sheet, if necessary.

1st child 2nd child 3rd child

Name

Date of birth

Sex

Place of birth

Nationality

Relationship to applicant

Relationship to sponsor (if you have one)

Travelling with applicant Yes/No Yes/No Yes/No

3.7 Please state where each child not travelling lives.

3.8 Are any of the children married, in a civil partnership, engaged to be married or in a relationship like a
marriage?

Yes No
If you have answered yes please give details.

Approved GPI Settlement Application Form Reviewed 03/18

SECTION 4. YOUR CIRCUMSTANCES WHEN YOU GET TO PITCAIRN
4.1: Do you have a Sponsor on Pitcairn?

Yes No If you have answered No please go to section 5.

4.2. What is the name of your Sponsor?

Date of Birth:

Place of Birth:

Sex:

Address:

4.3 What is your relationship to your Sponsor?

4.4 Do you intend to live with your Sponsor when you get to Pitcairn?

Yes No

SECTION 5. LIVING ON PITCAIRN

5. 1 Please give the full address of where you intend to live on Pitcairn.

5.2. Do you intend to work on Pitcairn? Yes No

If yes, please give details, including relevant qualifications, experience or specific skills. If applying under
Section 12 (1) (iii) of the Immigration Control Ordinance please provide details of relevant skills and how they
would contribute to the community.

Approved GPI Settlement Application Form Reviewed 03/18

5.3. Do you have any savings?

Yes No

If yes, do you have sufficient funds to sustain settlement on Pitcairn and build or rent a home on Pitcairn?
(Please refer to the FAQs for estimated costs.)

Yes No

You will be requested to provide proof of saving and assets as your settlement application proceeds.

5.4. If you have a sponsor on Pitcairn Island is he/she in receipt of Government of Pitcairn Islands public
funds?

Yes No

If yes, please give details:

5.5. Will you or your sponsor (if you have one) receive income from any other sources, including friends or
family?

Yes No

If you answered yes, please give details

SECTION 6. PREVIOUS APPLICATIONS AND TRAVEL

6.1 Is your current passport your first? Yes No

6.2 Have you ever travelled outside your home country? Yes No

6.3 Have you ever visited Pitcairn before? Yes No

6.4 Have you ever applied for a Pitcairn Entry Clearance before? Yes No

6.5 Have you ever been refused Entry Clearance for Pitcairn? Yes No

6.6 Have you ever been refused entry to Pitcairn or had leave to enter or remain cancelled? Yes No

6.7 Have you ever been deported, removed or otherwise required to leave Pitcairn? Yes No

6.8 Have you ever been refused a visa for another country? Yes No

If you have answered yes to any of questions 6.4 to 6.8, please complete questions 6.9 to 6.15. Otherwise go
to question 7.1.

Approved GPI Settlement Application Form Reviewed 03/18

6.9 Where was your previous application made?

6.10 When was it made?

6.11 What kind of visa were you applying for?

6.12 What was the reference number?

6.13 What happened? Please give the details of any forms which were served on you (e.g. Deportation
Order, APP104 or IS151A)

6.14 If you appealed against the decision, please give the date, reference number and outcome of the
appeal.

6.15 If this application is different in any way, please explain how

Please supply further information if relevant.

Approved GPI Settlement Application Form Reviewed 03/18

SECTION 7: CONVICTIONS AND OFFENCES
7.1 Do you have any criminal convictions in any country? Yes No

If you have answered yes, please answer questions 7.2 to 7.4. Otherwise go to question 7..

7.2 What was your conviction for?

7.3 When and where were you convicted?

7.4 What was your sentence?

7.5 Have you ever been concerned in the commission, preparation, organisation or support of acts of
terrorism, either within or outside the United Kingdom, or have you ever been a member of an organisation
which has been involved in or advocated terrorism in furtherance of its aims?

Yes No

7.6 Have you ever been concerned in the commission, preparation or organisation of genocide or crimes,
including crimes against humanity and war crimes, committed in the course of armed conflict?

Yes No

If you have answered yes to questions 7.5 or 7.6 please give details below.

Approved GPI Settlement Application Form Reviewed 03/18

SECTION 8. OTHER INFORMATION
Is there any other information you wish to give about your application? Please include your reasons
for applying to live on Pitcairn Island. Please tell us about any research you have done about living
on Pitcairn Island. Please include any other information you would like us to consider when
assessing your application. Attach additional pages if required.

Approved GPI Settlement Application Form Reviewed 03/18

Approved GPI Settlement Application Form Reviewed 03/18
SECTION 8. DECLARATION. To be completed by all applicants
You must now read and sign the declaration below. This must be signed by the applicant
personally and not by a representative or other person acting on his/her behalf. An application for
a person under the age of 18 may be completed and signed by the parent or legal guardian.

I hereby apply for an entry clearance for Pitcairn for myself and any dependants listed in this form.
The information I have given is complete and is true to the best of my knowledge. I also declare
that the passport photograph(s) submitted with this form is/are my own and those of my
dependents included in the application, and is/are a true likeness of myself and my dependants. I
confirm that if, before this application is decided, there is a material change in my circumstances
or new information relevant to this application becomes available, I will inform the Pitcairn Island
Office and the Immigration Officer on Pitcairn Island.

I am aware if I have made a false statement or declaration, I may be refused leave to enter on
arrival.

Applicant’s signature: ________________________ Date:

The Pitcairn Island Office is processing the personal data on this form and related data for the
purposes of promoting and protecting the United Kingdom, including its Overseas Territories, and
its citizens abroad. The data may be disclosed to other UK Government Departments, public
authorities and companies assisting in the processing and production of your visa.

GENERAL GUIDANCE
1. When should this form be used?
This form should be used if you are applying for a visa or entry certificate to settle on Pitcairn
Island, under one of the categories listed in section 1 of the form. Please note: if you wish to apply
as a Returning Resident, you should use the non-settlement application form.

2. Completing the form

Please answer all the questions as indicated. The form is designed to help determine whether
applicants meet the requirements of the Pitcairn Immigration Control Ordinance, and to assist
applicants to demonstrate that they meet those requirements. If you require additional guidance
about completing the form, please contact the Pitcairn Island Office admin@pitcairn.gov.pn. We
can only reply to questions relating to this form. If you require further information about living on
Pitcairn Island, please refer to the Pitcairn Island Website: www.pitcairn.gov.pn or the
Immigration Officer on Pitcairn Island: immigration@pitcairn.gov.pn.

You will need to demonstrate that you meet the requirements of the Pitcairn immigration rules.
Please refer to the Immigration Control Ordinance and study the FAQs, where details can be
found.

3. What documents should I provide?

All applicants must provide:
• The appropriate fee. This is non-refundable, regardless of the outcome of your application.
• A scanned copy of your valid passport photo page.
• Evidence to substantiate information given, including financial information, sponsor’s income (in
you have a sponsor) and proof of assets. (This will be requested when required.)

Approved GPI Settlement Application Form Reviewed 03/18