OFFICIAL: Sensitive
Personal Privacy
Department of Home Affairs Record of
My Health Declarations Responses
Terms and Conditions
View Terms and Conditions View Privacy statement
I have read and agree to the terms and conditions
Yes
Application context
Visa details
Give details of the visa subclass for which the applicant intends to apply.
Visa subclass: SKILLS IN DEMAND - 482
Has the applicant already submitted a visa application for this subclass and are they waiting for a
decision to be made by the Department on that application?
No
Primary applicant
Passport details
Enter the following details as they appear in the applicant's personal passport.
Family name: MOULVIBAZAR
Given names: MD
Sex: Male
Date of birth: 15 Jan 1987
Passport number: A06141585
Country of passport: BANGLADESH - BGD
Nationality of passport holder: BANGLADESH - BGD
Date of issue: 11 Jan 2023
Date of expiry: 10 Jan 2033
Personal Privacy
OFFICIAL: Sensitive
This form submitted by : australiavisaservice2024@gmail.com
Role(s) : Self-registered user
Submitted on : 09/02/2025 10:37
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OFFICIAL: Sensitive
Personal Privacy
My Health Declarations
Place of issue / issuing Bangladesh
authority:
National identity card
Does this applicant have a national identity card?
No
Place of birth
Town / City: BAGERHAT
State / Province: BAGERHAT
Country of birth: BANGLADESH
Relationship status
Relationship status: Married
Other names / spellings
Is this applicant currently, or have they ever been known by any other names?
No
Citizenship
Is this applicant a citizen of the selected country of passport (BANGLADESH)?
Yes
Is this applicant a citizen of any other country?
No
Other passports
Does this applicant have other current passports?
No
Other identity documents
Does this applicant have other identity documents?
No
Additional identity questions
Provide further details below, where available.
Previous travel to Australia
Has this applicant previously travelled to Australia or previously applied for a visa?
No
Contact details
Personal Privacy
OFFICIAL: Sensitive
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OFFICIAL: Sensitive
Personal Privacy
My Health Declarations
Country of residence
Usual country of residence: BANGLADESH
Residential address
Note that a street address is required. A post office address cannot be accepted as a residential
address.
Country: BANGLADESH
Address: BAGERHAT
BAGERHAT
Suburb / Town: BAGERHAT
State or Province: BAGERHAT
Postal code: 9300
Contact telephone numbers
Enter numbers only with no spaces.
Home phone:
Business phone:
Mobile / Cell phone: 0117516497979
Postal address
Is the postal address the same as the residential address?
Yes
Electronic communication
The Department prefers to communicate electronically as this provides a faster method of
communication.
All correspondence, including notification of the outcome of the application will be sent to:
Email address: australiavisaservice2024@gmail.com
Note: The holder of this email address may receive a verification email from the Department if the
address has not already been verified. If the address holder receives a verification email, they should
click on the link to verify their address before this application is submitted.
Accompanying members of the family unit
Are there any accompanying members of the family unit included in this application?
No
Travel details
Personal Privacy
OFFICIAL: Sensitive
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Personal Privacy
My Health Declarations
Travel details - MOULVIBAZAR, MD
Previous travel to Australia
Has the applicant been in Australia in the last 28 days?
No
Details of stay
Length of time the applicant Up to 12 months
intends to stay in Australia on
the above visa subclass:
Health declarations
In the last five years, has any applicant visited, or lived, outside their country of passport, for more
than 3 consecutive months? Do not include time spent in Australia.
No
Does any applicant intend to enter a hospital or a health care facility (including nursing homes) while
in Australia?
No
Does any applicant intend to work as, or study or train to be, a health care worker or work within a
health care facility while in Australia?
No
Does any applicant intend to work, study or train within aged care or disability care while in Australia?
Yes
Intention to work in age care or disability care
Give details of all applicants that intend to work in aged care or disability care during their stay in
Australia.
Name: MOULVIBAZAR, Md (15 Jan 1987)
Role: Disability Support
Give details: Australia health insurance for
Does any applicant intend to work or be a trainee at a child care centre (including preschools and
creches) while in Australia?
No
Does any applicant intend to be in a classroom situation for more than 3 months (eg. as either a
student, teacher, lecturer or observer)?
No
Has any applicant:
• ever had, or currently have, tuberculosis?
• been in close contact with a family member that has active tuberculosis?
• ever had a chest x-ray which showed an abnormality?
No
Personal Privacy
OFFICIAL: Sensitive
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Personal Privacy
My Health Declarations
During their proposed visit to Australia, does any applicant expect to incur medical costs, or require
treatment or medical follow up for:
• blood disorder
• cancer
• heart disease
• hepatitis B or C and/or liver disease
• HIV infection, including AIDS
• kidney disease, including dialysis
• mental illness
• pregnancy
• respiratory disease that has required hospital admission or oxygen therapy
• other?
No
Does any applicant require ongoing medical care or need special equipment, assistive technology or
assistance from others for daily living?
No
Declarations
Warning:
Giving false or misleading information is a serious offence.
The applicant declares that the individuals listed in this form:
Have read and understood the information available to them within this form, as well as information
available on the website of the Department about the My Health Declarations service and when it is
recommended to be used.
Yes
Have provided complete and correct information in every detail when completing this form.
Yes
Understand that if any of the information provided within this form changes, this may impact
which health examinations they are required to undergo, and that if they subsequently apply for
an Australian visa application, the Department of Home Affairs, its approved panel physicians or
onshore service provider may request additional health examinations be undertaken.
Yes
Understand that if any fraudulent or misleading information is found, any future visa application(s)
may be refused and/or any visa subsequently cancelled.
Yes
Will inform the Department in writing immediately as they become aware of a change in
circumstances (including a change in address) or if there is any change relating to the information
they have provided within this form, prior to any associated visa application being finalised.
Yes
Have read the information contained in the Privacy Notice(Form 1442i).
Yes
Personal Privacy
OFFICIAL: Sensitive
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My Health Declarations
Understand that the department may collect, use and disclose the applicant's personal information
(including biometric information and other sensitive information) as outlined in the Privacy
Notice(Form 1442i).
Yes
Consent to all medical information being submitted to the department for the purposes of
assessing their health for current or future Australian visa applications, and being transferred to the
department's electronic health processing system known as eMedical.
Yes
Consent to all medical information being available to the panel clinic(s) and/or the department's
migration medical services provider so that immigration health examinations can be undertaken via
the eMedical system.
Yes
We strongly advise the applicant(s) print and take a copy of the application to the health examination
appointment.
Personal Privacy
OFFICIAL: Sensitive
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