Form

Additional personal particulars

information

1221

About this form

Please use a pen, and write neatly in English using BLOCK LETTERS.

This is a supplementary form required to support your visa

application and is to be completed by all applicants who are
18years of age or over.

Tick where applicable

Important Please read this information carefully before you

complete this form. Once you have completed this form we
strongly advise that you keep a copy for your records.

Part A Your details

1

Your full name

(as shown in your passport or travel document)

Integrity of application

Family name

The Department of Immigration and Border Protection

(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.

Given names

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)

Name in Chinese Commercial Code Numbers (if applicable)

www.immi.gov.au

Date of birth

Telephone 131 881 during business hours

in Australia to speak to an operator (recorded
information available outside these hours).
Ifyou are outside Australia, please contact
your nearest Australian mission.

Place of birth

Important information about privacy

Your personal information is protected by law, including the
Privacy Act 1988. Important information about the collection,
use and disclosure (to other agencies and third parties,
including overseas entities) of your personal information,
including sensitive information, is contained in form 1442i
Privacy notice. Form 1442i is available from the departments
website www.immi.gov.au/allforms/ or offices of the
department. You should ensure that you read and understand
form 1442i before completing this form.

DAY

Home page
General
enquiry line

MONTH

YEAR

Suburb and
town/city
State/province/
region
Country

Sex

Relationship status

Male

Female

Married

Separated

Engaged

Divorced

De facto

Widowed

Never married or
been in a de facto
relationship

Citizenship or nationality (give details of all held)

DAY

MONTH

YEAR

Date granted

COMMONWEALTH OF AUSTRALIA, 2014

1221 (Design date 03/14) - Page 1

10 Your current residential address (this is the place where you currently live)
Note: A post office box, migration agent address or mailbox address is
not acceptable as a residential address.
Unit/Apartment number
Address (include street number and name)

Suburb and
town/city
State/province/
region
Country
Postal code

11 Your contact details

COUNTRY CODE

Home
telephone

AREA CODE
) (

NUMBER
)

Mobile/cell
All email
addresses

If insufficient space, give details at Part O

Additional details

12 Your proposed residential address in Australia (if known)

POSTCODE

Part B Travel details

13 Details from your passport/travel document
Passport/travel
document number
Country of passport/
travel document
DAY

MONTH

YEAR

Date of issue
Date of expiry
Place of issue/
issuing authority

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COMMONWEALTH OF AUSTRALIA, 2014

14 Do you currently have, or have you ever had, any national identity documents or numbers
(including birth registration numbers, social security cards etc)?
No
Yes

Give details

Type of identification document

Identification number shown

(if applicable)

Country of issue

Name shown on document

15 Have you ever had a visa refused or cancelled by, been refused entry to, or been deported from, any country?
No
Yes

Give details of dates, countries and circumstances

(If insufficient space, give details at Part O Additional details)

16 Have you previously held an Australian visa?

No
Yes

Give details in chronological order

(If insufficient space, give details at Part O Additional details)

Type of visa (eg. visitor,

student, business)

Place where
visa was issued

Your names shown on visa

Reason for visit

17 What is the general purpose of your journey/further stay?

18 If you are outside Australia, give details of your intended arrival

DAY

MONTH

YEAR

DAY

MONTH

YEAR

Intended date of arrival

Flight number
or vessel details
(if known)

19 Intended date of departure

COMMONWEALTH OF AUSTRALIA, 2014

1221 (Design date 03/14) - Page 3

20 Give details of any intended stopovers on your way to Australia

2. Relationship to you (eg. partner, sister, aunt)

Places of intended stopovers

Family name
Given names
DAY

MONTH

YEAR

Date of birth

21 Give details of any proposed onward locations after your departure

Suburb and
town/city of
birth
Country of birth

from Australia

If insufficient space, give details at Part O Additional details

22 Are you fully funding your trip?

No

Give details of the person/institution funding your trip

Full name

Part D Current employment details

24 Are you currently employed
No

Give details of how you occupy your time and

how you support yourself

Yes

Give details of your current employment

Name of institution (if applicable)

Address

POSTCODE

Telephone number
COUNTRY CODE
(

AREA CODE
) (

NUMBER
)

DAY

Email address of person/institution

MONTH

Employment commenced
Name of employer

Yes

Address of employer

Part C Details of travelling dependents/

family members
23 Give details of dependents/family members travelling to Australia with you

POSTCODE

Contact telephone
COUNTRY CODE
(

1. Relationship to you (eg. partner, sister, aunt)

AREA CODE
) (

Email address (if applicable)

Family name
Given names

Type of business
DAY

MONTH

YEAR

Date of birth

Occupation/Position

Suburb and
town/city of
birth
Country of birth

1221 (Design date 03/14) - Page 4

NUMBER
)

Detailed job description

COMMONWEALTH OF AUSTRALIA, 2014

YEAR

Part E Employment status in the last 10 years

25 Give details of your employment status in the last 10 years (including internships, work experience, self employment and periods of unemployment)
(If insufficient space, give details at Part O Additional details)
Date from
MONTH

YEAR

Name and address of employer/business.

(Do not use abbreviations)

Date to
MONTH

YEAR

Type of business/
other activities

Your occupation/position/title/duties/
how you spent your time if unemployed

Part F Military service

26 Have you had any military service?
No
Give details in chronological order
(If insufficient space, give details at Part O Additional details)

Yes

Date from
DAY

MONTH

YEAR

Date to
DAY

MONTH

YEAR

Country of service

Full name of Unit/

Battalion/Brigade

COMMONWEALTH OF AUSTRALIA, 2014

Rank

Duties

Country of
deployment

1221 (Design date 03/14) - Page 5

Part G Education and trade

qualifications

28 Describe any workshops, training, conferences or seminars you have

attended in the last 2 years

27 Give details of all post secondary qualifications

(list your most recent experience first)
1. Institution and city/campus

Qualification
Main subjects or duties

Year of award

2. Institution and city/campus

29 List all titles and describe any previous academic or research papers
you have had published

Qualification
Main subjects or duties

Year of award

3. Institution and city/campus

Qualification
Main subjects or duties

Part H Details of your contact in

Australia
30 Do you have contacts in Australia (including your sponsor, business

Year of award

4. Institution and city/campus

contacts, the person you will be staying with, a family relative or an

educational institution)?
No

Go to Part I

Yes

Family name
Given names

Qualification
Nature of relationship to you

Main subjects or duties

31 Current residential address of your contact

Year of award

(a post office box address is not acceptable as a residential address)

If insufficient space, give details at Part O Additional details

POSTCODE

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COMMONWEALTH OF AUSTRALIA, 2014

Part K Business visa

32 Contacts telephone numbers

COUNTRY CODE

Telephone
number

AREA CODE
) (

NUMBER

36 Proposed employment/business activity details

Name of employer

Mobile
Address of employment

All email
addresses

POSTCODE

33 Contacts current employment details

Nature of employment/business activities

Name of employer
Proposed duties/activities
Address of employer

37 Are you attending a conference/seminar in Australia?

POSTCODE

Type of business

No
Yes

Occupation/Position

Give full name of conference and (if applicable) attach an

abstract of the conference presentation

Duties

Part I Details of your journey to Australia

34 Only complete the section(s) relevant to you
If you:

38 Do you intend to inspect and/or negotiate the purchase of any

equipment during your stay in Australia?

have applied for a

Visitor visa

Go to Part J

have applied for a

Business visa

Go to Part K

have applied for a

Migration visa

Go to Part L

are a student, academic,

researcher or fellow

Go to Part M

No
Yes

Give details

Part J Visitor visa

35 Do you intend to do a course of study while in Australia?
No
Yes

Give details

Name of course
Name of the institution
Type of course

COMMONWEALTH OF AUSTRALIA, 2014

1221 (Design date 03/14) - Page 7

Part L Migration visas

Part M
Student/Academic/Researcher/Fellows

39 Do you intend to do a course of study while in Australia?

No
Yes

41 Give details of your proposed course/field of study in Australia

If you have organised your course, give details below

Name of course

(including name of course, type of course, thesis topic and research to

be undertaken)

Name of the institution

Type of course

40 Do you intend to work in Australia?

No
Yes

If you have organised your employment, give details below

Name of employer
Address of employer

POSTCODE

Type of business
Occupation/Position

Name of the institution

Duties
Name of supervisor (if applicable)
Family name
Given names

42 Do you intend to work in Australia?

No
Yes

If you have organised your employment, give details below

Name of employer
Address of employer

POSTCODE

Type of business
Occupation/Position
Duties

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COMMONWEALTH OF AUSTRALIA, 2014

Part N Additional information

44 Are there any other details you would like taken into consideration?

43 Give details of how you intend to use the knowledge/skills/research

obtained once you depart Australia

COMMONWEALTH OF AUSTRALIA, 2014

1221 (Design date 03/14) - Page 9

Part O Additional details

45

Question number

Additional information

Part P Declaration
WARNING: Giving false or misleading information is a serious offence.

46 I declare that:
the information I have supplied in this application is complete,
correct and up-to-date in every detail.
I have read and understood the information supplied to me.
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.
Signature of
applicant

DAY

MONTH

YEAR

Date

We strongly advise that you keep a copy of your application

and all attachments for your records.
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COMMONWEALTH OF AUSTRALIA, 2014