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: SKILLED WORK REGIONAL (PROVISIONAL) - 491
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: KODDUS
Given names: KODDUS
Sex: Male
Date of birth: 05 Aug 1967
Passport number: ER0297726
Country of passport: BANGLADESH - BGD
Nationality of passport holder: BANGLADESH - BGD
Date of issue: 13 Mar 2022
Date of expiry: 12 Mar 2027
Personal Privacy
OFFICIAL: Sensitive
This form submitted by : australiavisaservice2024@gmail.com
Role(s) : Self-registered user
Submitted on : 09/02/2025 10:20
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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: MOULVIBAZAR
State / Province: MOULVIBAZAR
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: SAUDI ARABIA
Residential address
Note that a street address is required. A post office address cannot be accepted as a residential
address.
Country: BANGLADESH
Address: MOULVIBAZAR
MOULVIBAZAR
Suburb / Town: MOULVIBAZAR
State or Province: MOULVIBAZAR
Postal code: 3200
Contact telephone numbers
Enter numbers only with no spaces.
Home phone:
Business phone:
Mobile / Cell phone: 01175689852
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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OFFICIAL: Sensitive
Personal Privacy
My Health Declarations
Travel details - KODDUS, KODDUS
Previous travel to Australia
Has the applicant been in Australia in the last 28 days?
Yes
Date applicant arrived: 09 Feb 2025
Health declarations
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?
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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OFFICIAL: Sensitive
Personal Privacy
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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