Soft Nagari Pvt Ltd
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Application Form
SERVICE AGREEMENT
Client Declaration
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Step
1
of 2
1. Has any applicant, or any other person included in this application ever OVERSTAYED a visa in any country (including Australia)?
Yes
No
Comment
2. Has any applicant or any other person included in this application ever had a visa CANCELLED in any country (including Australia)?
Yes
No
Comment
3. Has any applicant or any other person included in this application ever had a visa REFUSED in any country (including Australia)?
Yes
No
Comment
4. In the last 10 years, have you, or any other person included in this application, visited, or lived outside your country of passport for MORE than 12 consecutive months (other than Australia)?
Yes
No
Comment
5. In the last 10 years, have you, or any other person included in this application, visited, or lived outside your country of passport for LESS than 12 consecutive months (other than Australia)?
Yes
No
Comment
6. Has the applicant or any other person included in this application ever been CONVICTED OF AN OFFENCE in any country (including any conviction which is now removed from official records) (including traffic offences)?
Yes
No
Comment
7. Have you, or any other person included in this application possess any MEDICAL CONDITIONS that you are aware of?
Yes
No
Comment
8. Has any applicant ever been charged with any offence that is currently awaiting legal action (including traffic offences)?
Yes
No
Comment
9. Has any applicant ever had any outstanding debts to the Australian Government or any public authority in Australia?
Yes
No
Comment
10. Has any applicant ever served in a military force, police force, state sponsored / private militia or intelligence agency (including secret police)?
Yes
No
Comment
Next
11. Have you ever been diagnosed with Tuberculosis (TB)? Have you ever had to take treatment for Tuberculosis (TB)?
Yes
No
Comment
12. Have you ever been in close contact at work or at home with a person known to have Tuberculosis (TB)?
Yes
No
Comment
13. Have you ever been admitted to hospital and/or received medical treatment for an extended period for any reason (including for a major operation or treatment of a psychiatric illness)?
Yes
No
Comment
14. Do you suffer, or have you ever suffered, from mental health problems?
Yes
No
Comment
15. Have you ever been told you are HIV positive?
Yes
No
Comment
16. Have you ever had a positive Hepatitis B or Hepatitis C blood test?
Yes
No
Comment
17. Do you have or have you had cancer in the last 5 years?
Yes
No
Comment
18. Do you have high blood sugar / diabetes?
Yes
No
Comment
19. Do you have heart problems, including high blood pressure or a heart condition that you were born with?
Yes
No
Comment
20. Do you have a blood condition?
Yes
No
Comment
21. Do you have bladder or kidney problems?
Yes
No
Comment
22. Do you have a physical or intellectual disability that makes it difficult for you to function independently (for example, to move around or learn) or be able to work full-time? YES
Yes
No
Comment
23. Are you, or have you ever been, addicted to drugs or alcohol?
Yes
No
Comment
24. Are you taking any prescribed pills or medication (excluding oral contraceptives, over-the counter medication and natural supplements)? If yes, please list these.
Yes
No
Comment
25. Are you pregnant?
Yes
No
Comment
26
I agree
By signing below the applicant confirms that all information provided to the Agent is, to the best of the applicant’s knowledge and belief, true and current and that all documents supplied are genuine and authentic. I have also received the Schedule of Fees and Charges, Client Contract and Consumer Guide.
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