About this form: It is the responsibility of the person ...



|This form must be completed and submitted with a passport application where required. |

|Note: It is an offence under the Australian Passports Act 2005 to deliberately make a false or misleading statement. |

|Person lodging application | | |

|Details of the person completing |Your full name |      |

|this form | | |

| |Your current address |      |

|Details | |

|Details of the Statement |      |

| | |

|Declaration | |

|Declaration by the |I declare that the information I have given on this form is complete and correct and that I am aware that the penalty for |

|person completing |making a false or misleading statement either in writing or orally to obtain an Australia travel document is $110 000 or 10|

|this form |years imprisonment, or both. |

| |Signature | |Date |      |

| | | | |DD/MM/YYYY |

| |Full name (please print) |      |

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