Australian Government Department of Immigration ‘and Border Protection Appointment or withdrawal of an authorised recipient eee 956A © ‘Who should use this form? “This form should be used to notify the Department of Immigration and Border Protection (the department) that you + appointing an authorised recipient to receive documents that the department would otherwise have sent t0 you; or + withdrawing the appointment of your authorised recipient, Return the completed form to the office where you lodged ‘your application or for any other matter (eg, proposed visa cancellation), to the office of the department that is sponsible for that matter If you are unsure which office is responsible for your matter, this form may be submitted to the nearest office of the department, Do not use this form it: + you are appointing a migration agent or exempt person :o provide you with immigration assistance and they will also be your authorised recipieat. In this case the migration agent or exempt person should complete form 956 Advice by a migration agentiexempt person of providing immigration assistance. Who is an exempt person? The following people do not have to be registered 2s migration agents in order to provide immigration assistance: *+ close family member (spouse, child, adopted child, parent, brother or sister); + asponsor or nominator of a visa applicant; + amember of parliament or thei staff + an official whose duties include providing immigration + amember ofa diplomatic mission, consular post oF international organisation. An exempt person must not charge a fee for theie service. Its an offence for an exempt person to charge a fee for providing Immigration assistance and penalties of up t0 10 yearsjall can apply ‘Authorised recipient ‘An authorise recipient isa person appointed 10 receive documents from the department relating to matters arising, under the Migration Act 1958 (the Act) or the Migration Regulations 1994 on behalf of another person, The most common times an authorised recipient would be appointed is during visa application processes, vst ‘cancellation processes, sponsorship processes (including. ‘monitoring or sanctions) or ministerial intervention requests, The department cannot discuss matters relating t0 you with the authorised recipient unless they are also acting on your behalf as your migration agent/exempt person, or you have separately provided the department with consent to disclose your personal information to them. ‘You may only appoint one authorised recipient at any time fora particular application or matter The department wil send documents to the most recently appointed authorised recipient, The department is required under the Act to send your authorised recipient any documents relating to your matter (eg. visa application or cancellation of avis), that would otherwise have been sent to you. Under most circumstances, you will not receive a separate copy of the documents. You ate taken to have received any documents sent to your authorised, recipients as if they had been sent to you. You should be aware that the documents sent to your authorised recipient might include sensitive information about ‘matters such as your health and character, Ifyou change your authorised recipient or end their aappoiniment you must promptly advise the department. You ‘may use this form for that purpose. Dependent applicants All persons listed on ths form will be considered to appointed the same authorised recipient. AFaperson 16 years of age oF older wants to appoint a different authorised recipient they should complete a separate Form 9564.Consent to communicate electronically ‘The department may use a range of means to send documents to your authorised recipicat. However, electronic means such as fax or email will only be used if your authorised recipient indicates their agreement 10 receiving documents on your ‘To process your matter with the department (such as visa application or visa cancellation action), the department may need to communicate with you about sensitive information, for example, health, police checks, financial viability andl personal relationships. This means the information may be contained in the documents that are sent to your authorised recipient. Electronic communications, unless adequately ‘encrypted, are noe secure, and any information about you sent electronically to your authorised recipient may be viewed by others or interfered with IFyour authorised recipient agrees to the department sending your documents to them by. electronic means, the details they provide will only be used by the department for the purpose of sending documents. They. will not be added to any mailing lis. ‘The Australfan Government accepts no responsibilty for the security or integrity of any information sent to the department over the internet or by other electronic means. Important information about privacy Your personal information is protected by law, including the Privacy Act 1988, Important information about the collection, use and disclosure (Wo other agencies and third parties, including overseas entities) of your personal information, including sensitive information, is contained in form 14421 Privacy notice. Form 14421 is available from the department's ‘website www.border.govau/allforms/ or offices of the department. You should ensure that you read and understand before completing this form, Home page WWww.border.gov.au General Yeesrone 131881 ding busines hours enquiry line in sai speak oan percocet infomation saan outs these her yous cutie stata, las conect Your nares Asta isin lease keep these information pages for your referenceand Border Protection, Appointment or withdrawal of an authorised recipient 956A Pease se an, and rte ea gis ig BLOCK ETERS Ticteeaoleave [7] ‘re you using this form to notfy the department that you are: appointing an 7) Complete Part A and Part autre recpent Yodo nt end to cont Part withdrawing te |p Complete Part B and Part ¢ Seqociment ofan Yauco notreed cont Part autre eopet Part A — New appointment Your details Qa re you a: vise applicant [7] fidcone ony sponsor sponsor aplicant |] ‘ominatr oF nominator appicant [| proposer or repose annlicant visa holder whose visa i being considered for [| cancelation or has been cancelled person eiesing minster trenton 3 Doyouhave 18? clot O number (1072 mL) ves [> og? cient 0 umber (CO) Z (C) Full name (For an organisation, provide the name ofthe contact person) Tae: eZ) ts] miss) as] otter [ Famiy name [Nama paling tear jika ada, Given names [Nama Applicant / ] (Bau cron (© ovation rane aplani {si alamat Rumah ataupun Kantor 8) Address for correspondence (the same as business or residential adress, write #5 ABOVE) AS Above ® Telephone numbers Office nours Mobioet [[si Data No Hp Pribadi Bronte preys uct owe 1. Famiy name | Gwen names [Nama Spou lah menikah) 2. Famiy name Given names [Nama anak ke | Gjika ada) 3. Famiyname [ | Gen names [Nama Anak ke 2 (jika ada) {tere are more Wan 3 other persons, ge deta at Question 30 11 Hae you zopointed a migration agent or exemat cescn to provide you vith immigration assstance? we Ys [Give datas ofthe migration agenvexemat person Famiy name Given names appicabe: Migration Agent Registration {~ ‘Number (ARR Offshore Agent 1D Number Note: Your migration agentexemot person should complete form 958 ‘hice by a migration agont/exempt person of proving immigration assistance scape O18 edAppointment details }2) Are you appointing an authrised recipient in relation to an application @® 13 weapepamotne rent jrocess, a cancelation processor another maior eg. soonscship ‘montring and santon activity by the department, or only one tage ‘ofa two stage visa application, or mistrial intervention? (Y) Application process ‘i of apsicaton ae Subclass 500 aH Date ages Te) Natyettdges [7] [] Cancellation process Subclass of vsa Date vsa granted 7 ‘Another matter ~ give deals ‘inutRcint soaco, ge deta at Queston 30 Proiethe DBP D auber tne tact to the mat sed in Queston 12 in ean owe you are appeintng an autores rei (IGP Request Orumber (IO) | DIB? Transaction Reference ‘Number TAN) ISI DATA SEPERTI DI Authorise BAWAH INI site: el) vrs) tes) Femigpame (Wantoro Given ames | Ponco Aji 15 Dateot it [09-Oct-1984 16 business or eid adrass Gedung Wirausaha, 7h Floor Jalan HR Rasuna Said, Kav C-5, Kuningan Jakarta reves (2940 ‘17 _Aress tor corespondence (tte same as business or resident aces, wile AS ABOVE) ‘AS ABOVE 18 Weghone numbers Oficcnous [eC Mobiereet [6289611040300 |[s28s6110403 cs 19 does this personage othe department communicating with them by ox, ema or other eeconc means? No [ |» Goto Parte Yes []> Give detaits Foxoumber ca [email protected] | Email addross | ponco: > Goto Part c Scanner aU 218tbat thas Part C - Declarations Authorised recipient declaration Tiecone ony [Y) Appointment ‘understand that: ‘+ Ihave been appointed by te persons named in Part A of this form tobe their authorised recipient; and ‘+ as the autharsed recipient al documents that would otherwise ‘be sent tothe persons named in Part A wl be sent fo me, ‘including by electronic means as indicated in Question 19 (it apoicabe). [5 winrawa! of appointment | understand tna | am no fonger acing as authorised recpint ‘or the persons named in Pat B ofthis form in reltion to the ‘matter indicated in Pat B of tis form. Signature of auttorsed | Tandatangan Staf Australia recipient pa [| / 7 Your declaration Tick one only W) sppointment | delat have anpoted te autre rect named in Guesbon 14 fis fart rca a documents oeting tt mater nde n Question 12 on my beat 7) withdrawal of appointment | decare tate authorised ecient named in Question 25 fis form so lrger authorised to este doen ea othe atone in Custan 26 ony eta {understand tt tre corespancenee fom the deperent wit bs onto est adress at have proved in Queston 22 23 2 Lwin he department any changes tomy anes for coresancnce | etre a: + Rave ead te information contained inform 14421 Privacy noc. + lunerstand the deparment ny colt, use and csclse my ‘personal infomation {neuaing biometric informaton and othr sensitive iniomation as outlined inform 1442/Prvacy nlc. Your | 7 signatue | Dandatangan Applicant owe [77 Cianatsco of thor porgona 15 yar of age er der ho aro appinng or wincravng the appoiment of the same athorsed recipient in lation tothe same mater Signature Date Signature ‘We strongly advise that you keep a copy ofthis form for your records,a Part B - Withdrawing an appointment Your details Full name (Foran organisation, provide the name othe contact person) 25 Authorised recipient's details Fullname Family name | Family name Given names. [ a a Date of bith 77 Organisation name (Fappicabe) Telephone numbers Office ours im i Motiereet DIBP Clint 1D number (2D) (f4o0nn) Pee "Names of other persons 16 years of age or oder who are vitharawing te appointment ofthe same authorised recipont in ‘elton to the same matter Be 1. Famiy name [ Given panes 2, Family name : ] Given names ] 3. Famiy name ] ven names ] Your contact details Business of residental adress 23 24 I ress Teeshone number CommeIBE _wekcoue ck Otfice ours | Me > ‘Actkess for corespondence (tthe same as business or residential address, write AS ABOVE ‘Do you agresto the dparent communicating wth you by fx, emalor oer eectonic means? eo ves (71> ie detais Fccumber ) mall adress Given names ‘26 Axe you withdraning the appcintment ofan authorised reciient in ‘elation to an application pccess, a cancelation process o another ‘matter (9. sponsershio monitoring and sanction aby by the ‘partment, or only one stage ofa two siage wsa aplication, or minister intervention? | Application process “Type of application Date lodged [7 / 1 Cancetiation orocess Date vise granted [ | Anoter attr eeetas ‘insert space, give deta at Question 30 27 Provide the DBP ID number (i kaown) atached tothe mater in ‘elation fo wich you are withdrawing your appointment of he authorised recipient ‘IBP Request ID number ID) (IBP Tansacton Reference Number RN) apmAdditional details Ouestonrunber ‘ston inrmaton V4 data ovck be jiee ado ScMMnCAINCE ASIA SHS seipeynamona