Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 21. Has any applicant, or any other person included in this application ever OVERSTAYED a visa in any country (including Australia)?YesNoComment2. Has any applicant or any other person included in this application ever had a visa CANCELLED in any country (including Australia)?YesNoComment3. Has any applicant or any other person included in this application ever had a visa REFUSED in any country (including Australia)?YesNoComment4. 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)?YesNoComment5. 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)?YesNoComment6. 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)?YesNoComment7. Have you, or any other person included in this application possess any MEDICAL CONDITIONS that you are aware of?YesNoComment8. Has any applicant ever been charged with any offence that is currently awaiting legal action (including traffic offences)?YesNoComment9. Has any applicant ever had any outstanding debts to the Australian Government or any public authority in Australia?YesNoComment10. Has any applicant ever served in a military force, police force, state sponsored / private militia or intelligence agency (including secret police)?YesNoCommentNext11. Have you ever been diagnosed with Tuberculosis (TB)? Have you ever had to take treatment for Tuberculosis (TB)? YesNoComment12. Have you ever been in close contact at work or at home with a person known to have Tuberculosis (TB)? YesNoComment13. 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)? YesNoComment14. Do you suffer, or have you ever suffered, from mental health problems? YesNoComment15. Have you ever been told you are HIV positive? YesNoComment16. Have you ever had a positive Hepatitis B or Hepatitis C blood test? YesNoComment17. Do you have or have you had cancer in the last 5 years? YesNoComment18. Do you have high blood sugar / diabetes? YesNoComment19. Do you have heart problems, including high blood pressure or a heart condition that you were born with? YesNoComment20. Do you have a blood condition? YesNoComment21. Do you have bladder or kidney problems?YesNoComment22. 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 YesNoComment23. Are you, or have you ever been, addicted to drugs or alcohol?YesNoComment24. Are you taking any prescribed pills or medication (excluding oral contraceptives, over-the counter medication and natural supplements)? If yes, please list these. YesNoComment25. Are you pregnant?YesNoComment26 I agreeBy 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.Name *FirstLastEmail *Contact Number:Date SignatureClear SignatureSubmit