Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
1195
Identity declaration
Example of photograph
PHOTOGRAPH FRONT
PHOTOGRAPH BACK
This is a true
photograph of
Min 32mm
Max 36mm
Integrity of application
JOHN CITIZEN
(full name of applicant)
PSmith
(signature)
SIZE
South Australia
Northern Territory
Tasmania
Queensland
Victoria
Western Australia
Cairns office
PO Box 1269
CAIRNS QLD 4870
Form
1195
Identity declaration
Please use a pen, and write neatly in English using BLOCK LETTERS.
Corrections made with liquid paper are not acceptable.
Note: You must tell the department if your address changes after you
lodge this form.
Family name
Given names
DAY
MONTH
YEAR
Date of birth
Family name
Given names
POSTCODE
POSTCODE
Telephone numbers
POSTCODE
Telephone numbers
Work
(AREA CODE
Home
(AREA CODE
Work
(AREA CODE
Mobile/cell
Home
(AREA CODE
No
Mobile/cell
Transaction Reference Number (the number that you were given when
you lodged your online application)
Yes
Identity declaration
I declare that I have known (full name of the applicant who is applying
for citizenship)
Family name
Given names
for
I have endorsed the back of the applicants photograph with the words
This is a true photograph of [name of applicant] and signed the
photograph.
Signature
of person
making this
declaration
DAY
MONTH
YEAR
Date
DAY
MONTH
YEAR
Date
Applicants aged under 16 years responsible parent declaration
The responsible parent is to complete the following declaration if the
applicant is under 16 years of age.
I declare that I am the responsible parent of the applicant.
I declare that the information I have supplied in this form is
complete, truthful and correct in every detail.
I have read the information contained in form 1442i Privacy notice.
I understand the department may collect, use and disclose the
applicants personal information (including biometric information and
other sensitive information) as outlined in form 1442i Privacy notice.
Signature of
responsible
parent
DAY
DAY
MONTH
YEAR
YEAR
Telephone numbers
COUNTRY CODE
Telephone numbers
COUNTRY CODE
AREA CODE
NUMBER
Work
) (
Home
) (
Date
Date
Mobile/cell
AREA CODE
NUMBER
Work
) (
Home
) (
Mobile/cell