Professional Documents
Culture Documents
Please open this form using Adobe Acrobat Reader. 7 Country of citizenship
Either type (in English) in the fields provided or print this form
and complete it (in English) using a pen and BLOCK LETTERS.
Tick where applicable 3
8 Have you departed Australia?
No
Your details Yes
Given names
Postcode
Email address
3 Have you been known by any other names?
(including name at birth, previous married names, aliases)
No 12 Details of entry to Australia on the Temporary Resident visa
Day Month Year
Yes Give details
Date of first arrival
Family name
Place of arrival
Given names
Flight number/name
Reason for change: of ship (if known)
Deed poll Passport number when
you arrived in Australia
Marriage
Other 13 Details of departure from Australia
Day Month Year
If you have been known by any names other than these names, please
Date of last departure
provide documentary evidence. (All documents MUST be certified copies)
6 Country of birth
Office hours ( ) ( )
Indeterminate /
Sex Male Female Intersex / Unspecified
Mobile/cell
15 Provide details of your superannuation fund(s) 17 Is the person a registered migration agent, Australian legal practitioner
(Fund details must be provided because Certifications of Immigration or an exempt person?
Status will be sent electronically to individual funds) No
1. Fund name Yes Go to Question 19
18 Did you pay the person and/or give a gift for this assistance?
Fund address
No
Yes
Postcode
Options for receiving written
Fund email address
communications
19 All written communications about this application should be sent to:
2. Fund name (Tick one box only)
Myself
Fund address OR
Postcode
OR
OR
Your migration agent/legal practitioner/exempt
Legal person should complete form 956 Appointment
If there are more than 2 funds, further details can be included in your practitioner of a registered migration agent, legal
email to GCN.admin@homeaffairs.gov.au practitioner or exempt person
OR
Exempt person
Declaration
WARNING: Giving false or misleading information is a serious offence.
21 I declare that:
• the information I have supplied in this form is complete, truthful and
correct in every detail.
• I have read the information contained in form 1442i Privacy notice.
• I understand the Department may collect, use and disclose my
personal information (including biometric information and other
sensitive information) as outlined in form 1442i Privacy notice.
If applying for Certification of Immigration Status:
• I consent to the Department of Home Affairs sending a Certification
of Immigration Status containing my personal information, together
with attachments (if any), to the superannuation fund(s) nominated in
this form.
Your
signature
-
Day Month Year
Date
We strongly advise that you keep a copy of this form and all
attachments for your records.