Beruflich Dokumente
Kultur Dokumente
Undertaking declaration
1257
Given names
YEAR
DAY
MONTH
YEAR
DAY
MONTH
YEAR
DAY
MONTH
YEAR
Transaction
Reference Number
2. Family name
Given names
Date of birth
Passport number
Transaction
Reference Number
MONTH
Passport number
DAY
Date of birth
3. Family name
Given names
Date of birth
Passport number
Transaction
Reference Number
Please use a pen, and write neatly in English using BLOCK LETTERS.
Tick where applicable
4. Family name
Given names
Family name
Country of
passport
Given names
DAY
MONTH
YEAR
Date of issue
Date of expiry
Issuing authority/
Place of issue as
shown in your
passport
Male
Sex
Female
14 Are you:
DAY
MONTH
An Australian citizen
YEAR
Date of birth
Relationship status
Go to Question 16
Married
Separated
Engaged
Divorced
De facto
Widowed
Never married or
been in a de facto
relationship
Go to Question 15
A temporary resident
Give details
Visa label number
V
Visa grant number
POSTCODE
<
Postal address
(if same as the residential address, write as above)
16 Employment status
POSTCODE
Employed/
self-employed
10 Telephone numbers
COUNTRY CODE
Office hours
AREA CODE
) (
Employer/Business name
NUMBER
)
Address
Mobile/cell
Telephone
COUNTRY CODE
(
No
Yes
Give details
Email address
AREA CODE
) (
NUMBER
Student
Unemployed
Other
12 Place of birth
Town/city
Country
) (
Retired
COUNTRY CODE
Fax number
AREA CODE
Please specify
NUMBER
)
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Yes
18 I declare that:
the information supplied on this form is correct;
No
Yes
No
No
Yes
Yes
No
Yes
No
Yes
No
Yes
No
Yes
If you answered Yes to any of the questions at Question 17, you must
give ALL relevant details. If the matter relates to a criminal conviction,
please give the nature of the offence, full details of sentence and dates
of any period of imprisonment or other detention.
No
I will accept responsibility for the support and general welfare of the
child/children named on this form;
I accept that I must immediately advise the Department of Immigration
and Border Protection (the department) if I become aware that any
information provided in this form is incorrect or if there is a change
in my circumstances that is relevant to this undertaking at any time;
I accept that the Australian Federal Police or other Commonwealth
bodies may look into my history as necessary;
I will inform the department in writing if I withdraw my undertaking;
I have read the information contained in form 1442i Privacy notice; and
Yes
DAY
MONTH
YEAR
Date