Form

Undertaking declaration 1257

Department of Home Affairs

Important – Please read this information carefully Please open this form using Adobe Acrobat Reader.
before you complete this declaration. Once you Either type in the fields provided or print this form and
have completed this declaration we strongly complete it using a pen and BLOCK LETTERS.
advise that you keep a copy for your records. Tick where applicable 3

Who should use this form?

This form is to be completed by the person (21 years Part A – Child’s/Children’s
or older) who has been nominated by parent(s) or
legal guardian(s) to be responsible for a details
child/children (under 18 years of age) who:
• intend to stay in Australia; and 1 How many children are included in this undertaking?

• whose stay will not be in the company of one,

or both of his/her parent(s) or legal 2 Give details of each child included in this
guardian(s); and undertaking Provide details as shown in passport
• who will not be staying with a relative; and 1. Family name
• who is not a member of an organised tour
providing adequate maintenance and support Given names
arrangements for their stay in Australia. Day Month Year

Date of birth
The person nominated must provide an undertaking
to provide accommodation and be responsible for Passport number
the support and general welfare of the child during Transaction
their stay in Australia. This undertaking must be Reference Number
provided by a person who, in the belief of the
Minister, is of good character.
2. Family name
The person providing the undertaking should be
physically present in Australia for the period of Given names
the child’s/children’s intended stay Day Month Year

Date of birth
Important information about privacy
The Privacy Act 1988 contains 13 Australian Privacy Passport number
Principles which regulate the way that the Transaction
Department of Home Affairs (the Department) Reference Number
collects and handles personal information.
Information about how the Department collects, uses
3. Family name
and discloses personal information for its key
functions can be found in form 1442i Privacy notice. Given names
More information about the Department’s general
Day Month Year
information handling practices (including form 1442i)
can be found in the Department’s Privacy policy at Date of birth
https://www.homeaffairs.gov.au/access-and-
accountability/ our-commitments/privacy Passport number
Transaction
Reference Number

4. Family name

Given names
Day Month Year

Date of birth

Passport number
Transaction
Reference Number

If insufficient space attach additional details

© COMMONWEALTH OF AUSTRALIA, 2020 1257 (Design date 10/20) - Page 1

 Part B – Responsible 13 Details from your passport
Passport number PB2538042
nominee’s details
Country of passport AUSTRALIA
3 Family name DayMonthYear
DREVIKOVSKY Date of issue 02-Sep-2021
Given names Date of expiry 02-Sep-2031
STEFAN MARK
Issuing authority/place of issue as shown in your passport

AUSTRALIA
4 Other names you are, or have been, known by
(including name at birth, previous married names, aliases)

14 Are you:
An Australian citizen
Indeterminate / A permanent resident in Australia Go to
5 Sex Male Female Intersex / Unspecified Question 16 An eligible New Zealand citizen
Day Month Year A temporary resident Go to Question 15
6 Date of birth 08-Oct-1980
15 Are you currently holding or applying for an Australian visa?
7 Relationship status No
Married Separated Never married or Yes Give details
Engaged Divorced been in a de facto
relationship Visa label number
De facto Widowed
V <
Visa grant number
8 Current residential address
3/15-17 Thomas May Place
File number (if you are applying for a visa)
Westmead NSW
Postcode 2145

9 Postal address
(if same as the residential address, write ‘as above’)
16 Employment status
As above Employed/ Employer/Business name
self-employed
Redfield College
Postcode

Address
10 Telephone numbers
Country code Area code Number 855 Old Northern Road
Office hours (+61) ( 2 ) 96510323 Dural

Mobile/cell +61414445295 Postcode 2158

Telephone
11 In the course of deciding on the application, we may need Country code Area code Number
to contact you about the undertaking provided by you. ( +61 ) ( 2 ) 96514066
Do you agree to the Department communicating with Retired
you by fax, email, or other electronic means?
Student
No
Unemployed
Yes Give details
Country code Area code Number
Other Please specify

Fax number ( ) ( )

Email address stefan.drevikovsky@redfield.nsw.edu.au

12 Place of birth
Town/citySydney

CountryAustralia

1257 (Design date 10/20) - Page 2 © COMMONWEALTH OF AUSTRALIA, 2020

 If you answered ‘Yes’ to any question at Question 17, give details,
17 Have you ever:
including the date of the charge, the outcome and any penalty imposed.
• been charged with any offence that is
currently awaiting legal action? No Yes Also attach court documents (for example sentencing
remarks or court transcripts).
• been convicted of an offence in any country
Where relevant, provide a copy of all declared orders (for example,
(including any conviction which is now
any domestic or family violence orders, child protection orders, or
Yes
removed from official records)? No orders that prohibit the applicant from having contact with another
• been charged or convicted of family or person for their personal protection). You are only requested to
domestic violence offences or similar related declare an order where the applicant is the respondent or subject of
Yes the order. You are not asked to declare an order where the applicant
offences? No
is the person requiring personal protection.
• been the subject of a domestic or family
violence order, or any other order, of a tribunal
or court or other similar authority, for the
Yes
personal protection of another person? No
• been the subject of an arrest warrant or
Yes
Interpol notice? No

• been found guilty of a sexually based offence

involving a child (including where no
Yes
conviction was recorded)? No
Yes
• been named on a sex offender register?
No
Yes
• been acquitted of any offence on the grounds
of unsoundness of mind or insanity? No Yes

• been found by a court not fit to plead? No

• been directly or indirectly involved in, or

associated with, activities which would Yes
represent a risk to national security in
Australia or any other country? No

• been charged with, or indicted for: genocide,

war crimes, crimes against humanity, torture,
Yes Part C – Undertaking
slavery, or any other crime that is otherwise of
a serious international concern? No
declaration
• been associated with a person, group or
organisation that has been/is involved in
Yes
18 WARNING: Giving false or misleading information is a
criminal conduct? No
serious offence. I declare that:
• been associated with an organisation engaged
• the information supplied on this form is correct;
in violence or engaged in acts of violence • I will be residing in Australia for the period
(including war, insurgency, freedom fighting, of the above child’s/children’s stay;
Yes
terrorism, protest) either overseas or in • I will ensure that the adequate accommodation is available to the
Australia? No child/children during the child’s/children’s stay in Australia;

• served in a military force, police force, state Yes

• I will accept responsibility for the support and general
sponsored/private militia or intelligence welfare of the child/children named on this form;
agency (including secret police)? No • I accept that I must immediately advise the Department if I
become aware that any information provided in this form is
• undergone any military/paramilitary training, Yes
incorrect or if there is a change in my circumstances that is
been trained in weapons/explosives or in the
relevant to this undertaking at any time;
manufacture of chemical/biological products? Yes • I accept that the Australian Federal Police or other
No • been involved in people smuggling or people
Commonwealth bodies may look into my history as necessary;
trafficking offences? No Yes • I will inform the Department in writing if I withdraw my undertaking;
• been removed, deported or excluded from any • I have read the information contained in form 1442i Privacy notice; and
country (including Australia)? No Yes • I understand the Department may collect, use and disclose my
• overstayed a visa in any country (including personal information (including biometric information and other
Australia)? No sensitive information) as outlined in form 1442i Privacy notice.

• had any outstanding debts to the Australian Yes

Signature of
Government or any public authority in responsible
Australia? No
nominee -
Day Month Year
Date 01-Jun-2024

We strongly advise that you keep a copy of this

declaration and all attachments for your records.
© COMMONWEALTH OF AUSTRALIA, 2020 1257 (Design date 10/20) - Page 3