Form

Application for a Work Permit Visa 1401

AFIX PHOTO

. 7 Details from your passport

Either type (in English) in the fields provided or print
Passport number
this form and complete it (in English) using a pen
and BLOCK LETTERS. Country of passport

Nationality as
Tick where applicable shown in passport
Day Month Year

Note: Any reference in this form to ‘country’ refers to ‘foreign Date of issue
country’ which is defined in paragraph 22(1)(f) of the Acts
Date of expiry
Interpretation Act 1901 as any country (whether or not an
independent sovereign state) outside Australia and the Issuing authority/place of issue as shown in your passport

external territories.
If you hold more than one passport please provide
details of those passports
Part A – Your details Your full name as it appears in the
1 Your full name, exactly as it appears on the passport on passport Family name
which you will be travelling to Australia
Family name Given names

Passport number

Given names Country of passport

Day Month Year

Date of issue
2 Have you been known by any other names? Date of expiry
(including name at birth, previous married
names, aliases) No Issuing authority/place of issue as shown in your passport
Yes Give details
Note: Visa applicants must hold a valid passport to be granted a visa. It
is recommended that the passport be valid for at least 6 months.
If you change your passport after you have been granted
Indeterminate / the visa you must notify the nearest Australian mission,
3 Sex Male Female Intersex / Unspecified Visa Application Centre or office of the Department.
If you do not provide the Department with the details of any
Day Month Year new or additional passport you use to travel to Australia,
you will experience significant delays at the airport and
4 Date of birth
could be denied permission to board your plane.

5 Place of birth
8 Do you hold any citizenship other than that shown as
Town/city your country of passport above?
No Yes Give details
Country

6 Relationship status
Married Separated Never married or 9 Details of identity card or identity number issued to you by
been in a de facto your government (if applicable) eg. National identity card.
Engaged Divorced
relationship Note: If you are the holder of multiple identity numbers because
De facto Widowed
you are a citizen of more than one country, you need to enter
the identity number on the card from the country that you live in.

Identity number

Country of issue
1208 (Design date 10/20) - Page 5
10 Usual occupation 14 Current residential address
(If applying in Australia, please give your current address in
Australia) Note: A post office box address is not acceptable
as a residential address. Failure to give a residential address
11 What type of employment do you intend to seek during your stay? will result in your application being invalid.

Postcode
12 Qualifications
15 Address for correspondence
(This may be required by the Department to communicate with you about your
application. If the same as your residential address, write ‘AS ABOVE’)

13 Provide evidence of how you obtained your English

language proficiency (eg. IELTS 4.5 or equivalent) Postcode

Note: This is not required for second or third

Work and Holiday visa applications. 16 Your telephone numbers
Completed a diploma Country code Area code Number
or degree and the Office hours ( ) ( )
tuition was in English
Undertaken an English Give details of your English test After hours ( ) ( )
language proficiency Cambridge English: Advanced
Mobile/cell
test within the last 12 (CAE) test (also known as
months Certificate in Advanced English)
(Note: CAE results must be from a test
17 Do you agree to the Department communicating with you by fax,
taken on or after 1 January 2015) email, or other electronic means? (Providing an email address will
International English Language allow for more efficient processing of your application)
Testing System (IELTS) No
Occupational English Test (OET) Yes Give details
Country code Area code Number
Pearson Test of English
Academic (PTE Academic) Fax number ( ) ( )

Test of English as a Foreign Language

Email address
internet-Based Test (TOEFL iBT)

Date of test Please ensure you have access to this email while
Day Month Year
your application is being processed

18 If you are outside Australia, date of proposed travel to Australia

Test location Day Month Year

(country where test was taken)

Test reference number – Depending on 19 Do you have sufficient funds for the initial period of your stay in Australia?

the test you have taken, this may also be Note: You may be asked to provide evidence (eg. bank statement).
known as a Reference Number, Test
No
Report Form Number, Registration ID or
Yes
Registration Number.

20 Do you have a return or onward ticket or the funds for

a fare to depart Australia?
Other Give details – for example, applying
as a USA passport holder, have Note: You may be asked to
completed an English ‘Bagrut exam’ provide evidence. No Yes
in the level of 3 study units.

21 Do you have any dependent children that will

accompany you to Australia? Note: You cannot be
accompanied by dependent children on this visa. No
Yes
 26 Have you:
• ever had, or currently have, tuberculosis?
• been in close contact with a family
member that has active tuberculosis?
• ever had a chest x-ray which showed an abnormality?
Part B – Health No
22 In the last 5 years, have you visited, or lived, outside your Yes Give details
country of passport for more than 3 consecutive months?
No
Yes Give details

1. Country(s)
DayMonth Year Day Month Year

Date from to
27 During your proposed visit to Australia, do you expect to incur
medical costs, or require treatment or medical follow up for:
2. Country(s) • blood disorder;
Day Month Year Day Month Year • cancer;
• heart disease;
Date from to
• hepatitis B or C and/or liver disease;
• HIV infection, including AIDS;
3. Country(s) • kidney disease, including dialysis;
Day Month Year Day Month Year • mental illness;
Date from to • pregnancy;
• respiratory disease that has required
hospital admission or oxygen therapy;
23 Do you intend to enter a hospital or a health care • other?
facility (including nursing homes) while in Australia?
No
No
Yes Give details
Yes Give details

28 Do you require assistance with mobility or care

24 Do you intend to work as, or study to be, a doctor, due to a medical condition?
dentist, nurse or paramedic during your stay in Australia?
No
No
Yes Give details
Yes Give details

29 Do you hold health insurance to cover your stay in Australia?

25 Do you intend to work, or be a trainee, at a child care
centre (including preschools and creches) while in Australia? Note: See page 1 of this form for further
No information about health insurance. No
Yes Give details Yes

30 Have you undertaken a health examination for an

Australian visa in the last 12 months?
No
Yes Give details (including HAP ID if available)
 Part C – Signatures Australian values statement
I confirm that I have read, or had explained to me, information provided

31 BIOMETRICS DECLARATION AND CONSENT by the Australian Government on Australian society and values.

This declaration and consent is for offshore visa applicants. I understand that Australian society values:
If I am requested or required to provide my • respect for the freedom and dignity of the individual;
• freedom of religion (including the freedom not to follow a particular
fingerprints and facial image: I consent to:
religion), freedom of speech, and freedom of association;
• the collection of my fingerprints and
• commitment to the rule of law, which means that all
facial image. I declare that:
people are subject to the law and should obey it;
• I understand that my fingerprints and facial image and my
• parliamentary democracy whereby our laws are determined by
biographical information held by the Department may be
parliaments elected by the people, those laws being paramount
given to Australian law enforcement agencies to help identify
and overriding any other inconsistent religious or secular ‘laws’;
me, to help determine my eligibility for grant of the visa I
• equality of opportunity for all people, regardless of their gender,
have applied for, and for law enforcement purposes.
sexual orientation, age, disability, race, or national or ethnic origin;
I consent to:
• Australian law enforcement agencies disclosing my biometric,
• a ‘fair go’ for all that embraces:
biographical and criminal record information to the – mutual respect;
Department for any of the purposes outlined above; and – tolerance;
• the Department using the information obtained for the purposes of – compassion for those in need;
the Migration Act 1958 or the Australian Citizenship Act 2007. – equality of opportunity for all;
• the English language as the national language, and
Signature of as an important unifying element of Australian society.

applicant  I undertake to conduct myself in accordance with

these values of Australian society during my stay
Day Month Year
in Australia and to obey the laws of Australia.
Date
Signature of
32 DECLARATION
WARNING: Giving false or misleading information
applicant 
or documents is a serious offence. Day Month Year

I declare that: Date

• the information on this form is complete, correct and up-to-date; Please check all questions are answered. If your form is incomplete,
• I have read the notes at the front of this application, there may be delays in processing your application.
and am aware that I am required to abide by the
conditions that are placed on my visa; We strongly advise that you keep a copy of your
• after applying, I will notify the Department of any change in application and all attachments for your records.
my circumstances including my address details;
• 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;
• I understand that if any fraudulent documents or false or misleading
information has been provided with this application, or if I fail to
satisfy the Minister of my identity, my application may be refused and
I, and any other member of my family unit, may become unable to be
granted a visa for specified periods of time; and
• if documents are found to be fraudulent or information to be incorrect
after the grant of a visa, the visa may subsequently be cancelled.

• I have read and understood that I am liable for the cost of

any health related services that I receive while in Australia.
This does not include costs otherwise covered, such as by
health insurance, Medicare (if eligible), or treatment for
certain community health risks such as tuberculosis.
• I understand that if my visa ceases to be in effect and I do
not hold another visa to remain in Australia at that time, I will
be an unlawful non-citizen under the Migration Act 1958. As
such, I will be expected to depart from Australia, and be
subject to removal under the Migration Act 1958.

1208 © COMMONWEALTH OF AUSTRALIA, 2021