Queensland Border Pass (Non-resident)

Reference ID: kadrian-447216

Submitted: 04/04/2020, 6:34:31 pm

Personal details

Name: David Kadrian

Application is for: Single (see below for names/s)

Residential address: 4/61 Derham Street, Port Melbourne victoria 3207

Email: kadrianator@gmail.com

Reason for entering Queensland

Category of travel: Health Services

✔ The information I have provided in this form is true and correct. I acknowledge that providing false
information is an offence under the Public Health Act 2005 which may render me be liable to a fine
of up to 100 penalty units.

✔ I have confirmed my eligibility for the exemption I am applying for.

The collection of this information is authorised by the Public Health Act 2005 (Qld). The information
will be used for the administration and enforcement of the Public Health Act 2005. The Queensland
Police Service and or Queensland Health may disclose some or all of this information to other State
and Federal Government agencies as authorised or required by legislation or in accordance with the
Information Privacy Act 2009 (Qld).

Name/s of those requesting entry to Queensland

David Kadrian

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