Beruflich Dokumente
Kultur Dokumente
Important – Please read this information carefully before you Document checklist
complete your request. Once you have completed your request
Please ensure all required documents are submitted with your
we strongly advise that you keep a copy for your records.
request. See Part E – Checklist.
Please open this form using Adobe Acrobat Reader. 6 Do you agree to the Department communicating with you by fax or email?
Either type (in English) in the fields provided or print this form No
and complete it (in English) using a pen and BLOCK LETTERS.
Yes Give details
Tick where applicable 3
Fax number (AREA CODE )
The information given in Part A should contain details of the person Given names
making the request. DAY MONTH YEAR
Date of birth
2 Title Mr Mrs Miss Ms
Sex Male Female
Other
Date of expiry
Issuing authority/
POSTCODE Place of issue as
shown in your
passport
5 Your telephone numbers
Office hours (AREA CODE ) 10 Have you been known by any other names?
(including name at birth, previous married names, aliases)
After hours (AREA CODE )
No
Mobile/cell Yes Give details
Family name
Given names
DAY MONTH YEAR
Date of name
change
© COMMONWEALTH OF AUSTRALIA, 2018 1359 (Design date 07/18) - Page 3
11 Information about arrival/departure
Part C – Consent for agent/third party
Date range of movements required
to act
DAY MONTH YEAR DAY MONTH YEAR
15 Are you requesting movement records for another person (person
from to described in Part B)?
No Go to Part D
12 Were you born in Australia?
DAY MONTH YEAR Yes Please have them complete the authorisation below
No Date of first arrival
Family name
DAY MONTH YEAR
Yes Date of first international Given names
movement DAY MONTH YEAR
Date of birth
13 Did you arrive in Australia as a child with your parent(s)/family
members? Address
No
Yes Give details POSTCODE
Date
14 Why do you require the movement records?
Signature
of person in
Part A -
DAY MONTH YEAR
Date
Note: Both parties must attach a scanned colour copy or certified proof
of identity.
from to
OR
DAY MONTH YEAR
1. Date of arrival/
departure (if known)
Name of ship/airline
Port of arrival/departure
DAY MONTH YEAR
2. Date of arrival/
departure (if known)
Name of ship/airline
Port of arrival/departure
18 Why do you require the movement records? Request note created in ICSE
Name of client
service officer
19 WARNING: Giving false or misleading information is a serious offence. Contact details
I certify that there are no orders: Address
• restricting my access to these documents; or
• giving parental responsibility for the child named in this request to POSTCODE
another person.
Telephone number (AREA CODE )
Your
signature Email address
- DAY MONTH YEAR