Application for Western Australian Government State ...



Payment invoice/receipt no. _______________Application for Western Australian Government State nomination for a business visaBusiness Innovation and Investment (Provisional) visa (subclass 188) – Significant Investor StreamYou must attach all of the following. Please place a cross (X) in each box to confirm you have attached: FORMCHECKBOX A copy of your passport bio-data page FORMCHECKBOX Evidence of any assets claimed in the Statement of Assets and LiabilitiesApplicant declarationI declare that FORMCHECKBOX All of the information contained in my application is correct; FORMCHECKBOX I have assessed myself against the Department of Home Affairs 188 Business Innovation and Investment (Provisional) visa Significant Investor Stream criteria and believe I meet all the requirements; and FORMCHECKBOX I will contact the Business Migration Centre upon my first entry after visa grant to arrange my first entry interview with a Business Migration Officer.Name of applicant:______________________Signature of applicant:______________________Dated (dd/mm/yyyy): FORMTEXT ?????_____Migration agent or authorised representative declarationAs the appointed migration agent FORMCHECKBOX or authorised representative FORMCHECKBOX for the above named applicant I declare that FORMCHECKBOX All the information contained in this application is correct; FORMCHECKBOX The applicant has read and understands the contents of this application; and FORMCHECKBOX Migration agents only - I have assessed the applicant against the Western Australian government State nomination requirements and the Department of Home Affairs criteria for this visa subclass and believe they are a qualifying applicant.Migration agent/authorised representative name:_________________Migration agent/authorised representative signature:__________________Dated (dd/mm/yyyy): FORMTEXT ?????______Please note: The Business Migration Centre reserves the right to request applicants, agents or representatives of applicants for State nomination to formally attest to the accuracy of the information contained in this application or its attachments.Western Australian GovernmentState nomination application form 188 Significant Investor VisaApplicant details:Family name: FORMTEXT ?????___________________________________________________________________Given names: FORMTEXT ?????__________________________________________________________________ Gender: FORMCHECKBOX M / F FORMCHECKBOX Date of birth (dd/mm/yyyy): FORMTEXT ????? ________ Age: FORMTEXT ????? _______________Address: FORMTEXT ?????_______________________________________________________________________ __________________________________________________________________________________ Country:______________________________________ Postcode: FORMTEXT ?????__________________Telephone: FORMTEXT ?????______________________________ Mobile: __________________________Email address: FORMTEXT ?????_________________________Level of English language ability: FORMTEXT ????? _________________________Details of any Australian visa held: FORMTEXT ????? ________________ Expiry Date: ______________________Passport number: FORMTEXT ?????Country of issue: FORMTEXT ?????___________________Date of issue of passport (dd/mm/yyyy): FORMTEXT ?????Have you applied for nomination from any other Australian State or Territory government?Yes FORMCHECKBOX No FORMCHECKBOX If yes, name of State or Territory government: FORMTEXT ?????___________________Secondary applicants and dependents:Name of secondary applicant: FORMTEXT ?????____________________ Current country of residence: FORMTEXT ?????_____________________Name of dependent (1): FORMTEXT ????? Country of current study: FORMTEXT ?????________Name of dependent (2): FORMTEXT ????? Country of current study: FORMTEXT ?????________Name of dependent (3): FORMTEXT ????? Country of current study: FORMTEXT ?????________Name of dependent (4): FORMTEXT ????? Country of current study: FORMTEXT ?????________Migration agent or authorised representative details:Are you using the services of a migration agent or authorised representative? Yes FORMCHECKBOX No FORMCHECKBOX If yes, please provide migration agent or authorised representative details:Name: FORMTEXT ?????________________________________________________________________________Business name: FORMTEXT ?????_________________________________________________________________Postal address: FORMTEXT ?????_________________________________________________________________Country: FORMTEXT ?????Postcode: FORMTEXT ?????____________Telephone: Mobile: FORMTEXT ?????Office: FORMTEXT ?????____________________________Email address: FORMTEXT ?????_______________________________STATEMENT OF ASSETS AND LIABILITIESApplicant name: FORMTEXT ?????_______ Statement date _______________I declare that I have listed all my main assets (in Australia and overseas):Applicant’s signature: ______________________ Date of signature: ___________________Do you have any assets in Australia? Yes FORMCHECKBOX No FORMCHECKBOX If yes, please mark those assets below with “X” If yes, in which State of Australia are those assets held: _____________________________________ASSETSAUD $LIABILITIESAUD $Family home FORMTEXT ?????Home mortgage FORMTEXT ?????Investment property FORMTEXT ?????Investment loan FORMTEXT ?????Household contents FORMTEXT ?????Personal loan FORMTEXT ?????Motor vehicle FORMTEXT ?????Motor vehicle loan FORMTEXT ?????Net assets in business FORMTEXT ?????Business loan FORMTEXT ?????Superannuation FORMTEXT ?????Other loans/liabilities FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Cash at bank FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Term deposits FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Shares FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Managed investments FORMTEXT ?????Other assets(please list) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????TOTAL ASSETSAUD$ FORMTEXT ?????TOTAL LIABILITIESAUD$ FORMTEXT ?????NET ASSETSAUD$ FORMTEXT ?????Currency must be in Australian Dollars currency/converter/Please attach evidence of any assets claimed in the Statement of Assets and Liabilities.A balance sheet is required for net assets in business. Evidence is required for any amounts claimed against cash at bank, term deposits, shares, managed investments or property or gifts.Business Visa 188 Significant Investor Visa StreamBusiness or investment activity.Qualifications and dates completed: FORMTEXT ????? FORMTEXT ?????Past business and employment history (include company name, your role and dates) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Notable achievements in your business or investment career (eg. growth, profitability, major contracts): FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Have you (or your partner) been involved in any business or investment activities that are unacceptable in Australia?Yes FORMCHECKBOX No FORMCHECKBOX Do you (or your partner) have a history of bankruptcy or liquidation proceedings? Yes FORMCHECKBOX No FORMCHECKBOX If you have answered yes to questions 2 or 3 please provide further information: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????If you are a business owner applicant:Name of your business or businesses. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Describe the activities of your business or businesses. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Your management role and responsibilities in your business or businesses FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Number of staff employed in your business or businesses (full time equivalent): FORMTEXT ????? FORMTEXT ?????Turnover, net business assets and your ownership interest in your businessPlease provide the turnover figures, net business assets and your ownership interest in your business or businesses for the most recent financial year. Amounts must be in Australian Dollars. You must use the historical exchange rate for each fiscal year nominated businessTurnover:assets: OwnershipYear: __________AUD$_____________ AUD$____________interest: __________%If you are an investor applicant:Please provide details of your investments. Investment type: Ownership % Dates involved1. _______ ___ ________ ____ % From: _ __ To:____________2. _______ ___________ ________% From:________ To:____________ 3. ___________________ ________% From:__________To:____________ 4. __________ _ _________% From:__________To:____________ Describe how you manage your investments: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????If you are not a business owner or an investor please advise how you have accumulated the funds to be used for the complying investment. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????The net value of your (or your partner’s, or you and your partner’s combined) assets must be at least A$5,000,000.What is the current value of your net assets as shown in your Statement of Assets and Liabilities (page 3). Amount must be in Australian dollars.AUD$ ___What are the total net assets to be in Western Australia (total net assets includes your complying investment and personal assets).AUD$ __ (minimum AUD$5 million)What assets will you liquidate to fund your complying investment? Please attach evidence of the value of the assets to be liquidated, including any gifts. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????You must make an investment in Australia within the complying investment framework of at least AUD$5 million.Provide details of your intended complying investment including the type of investment and the name and the amount that will be invested into each State or Territory.Investment type and name of investment Amount State(s)/Territory(ies)(eg Australian Venture Capital Funds, Managed Funds, other balancing investments)Eg. Managed Fund & name of fund AUD$ 3,000,000 WA and NSW ____________________________ AUD$____________ ______________________________________________________ AUD$____________ ______________________________________________________ AUD$____________ ______________________________________________________ AUD$____________ ______________________________________________________ AUD$____________ __________________________If any amount of your investment is in a managed fund, does the fund have “loan back” arrangements: FORMCHECKBOX Yes FORMCHECKBOX No Intended Western Australian complying investment amount: AUD$________________Intended Non Western Australian complying investment amount: AUD$________________ Total amount of your proposed complying investment to be made in Australia. AUD$ ___ (minimum AUD$5,000,000) Term of investmentI understand that the investment must be held for the term of the visa. I understand that I will be required to have my investment for longer than 4 years. The investment must still be in place until the date your visa expires. FORMCHECKBOX Yes Contribution to the Western Australian economy:Applicants must demonstrate how their Western Australian business or investment will contribute to the State’s economy:In addition to your net assets to be in Western Australia, please advise if your investment will:Create any new employment; FORMCHECKBOX Yes FORMCHECKBOX No If yes, how many new jobs: ____________________Expand trade in Western Australian goods and/or services; FORMCHECKBOX Yes FORMCHECKBOX No If yes, give details: ___________________________Develop export markets for Western Australian products or replace imports; FORMCHECKBOX Yes FORMCHECKBOX No If yes, give details: ___________________________Introduce any new skills, expertise, technology or innovation; FORMCHECKBOX Yes FORMCHECKBOX No If yes, give details: ___________________________Invest in a regional area. FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, provide name of region: _________________Do you have any funds or investments currently in Western Australia? FORMCHECKBOX Yes FORMCHECKBOX No If yes, please advise:The type of funds or investments: ____________________________________________________________________________The amount of funds:AUD$_____________________________________________ Do you or your family plan to reside in Western Australia? FORMCHECKBOX Yes FORMCHECKBOX No If yes, please advise where: city/town____________________You will maintain your funds in Western Australia on maturity of your complying investments. FORMCHECKBOX Yes FORMCHECKBOX NoPlease provide evidence of how you will maintain all your funds in Western Australian assets upon maturity of your complying investment.Please list the assets in which the funds are to be invested:_____________________________________________________________________________Provide the following information or respond with “N/A” if it does not apply to you:Have you ever visited Australia or Western Australia? If yes, please advise which State you visited, when you visited, for how long and the reason for the visit.State visited: Dates visited: Length of visit: Reason for visit:________________ ____________________ ______________ ___________________________________ ____________________ ______________ ___________________________________ ____________________ ______________ ___________________Do you have any future planned visits to Western Australia? (if yes, advise date) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Do you have any friends or business associates in Australia? If yes, where are they located? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Do any of your family members reside or study in Australia? If yes, in which State are they located?Please include any additional information you would like considered in your application.Before submitting this application form, please ensure you have completed all sections and have attached supporting documents where required. Decisions may be made on the information provided, without seeking further clarification.All documents submitted with your State Nomination application will be kept by the Business Migration Centre. Please note: Only send copies of requested documents, do not send any original documents. Use only a paper clip to fasten the documents together. Do not bind or staple your application. Please send your application to: Business Migration CentreSmall Business Development CorporationGPO Box C111PERTH, WESTERN AUSTRALIA 6001 Telephone:(+618) 6552 3300 Facsimile:(+618) 6552 3399Email:businessmigration@smallbusiness..au ................
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