Form

Nomination of student dependants

About this form

Important Please read this information carefully before you
complete this nomination. Once you have completed this
nomination we strongly advise that you keep a copy for your
records.
This form is to be used by Student (Temporary) (Class TU) visa
holders in Australia who wish to nominate members of their
family unit to join them in Australia. It is to be used where the
family unit members are applying separately from the student
visa holder outside Australia.

919

evidence of payment of the Overseas Student Health Cover

premium in favour of each nominated family unit member.
Where stated, original documents must be provided. Where
copies of original documents are required, the copies must be
certified copies. In Australia, a certified copy is one certified by
a Justice of the Peace or a Commissioner for Declarations or a
person before whom a statutory declaration may be made under
the Statutory Declarations Act 1959.

Charges

Under the migration legislation, a person is a member of the

family unit of a Student (Temporary) (Class TU) visa holder if
the person is:

Your dependant(s)s completed student visa application form,

together with the correct Visa Application Charge and this
nomination, can be lodged at an Australian mission overseas.

a partner (including spouse or de facto partner) of the

student visa holder; or

The Visa Application Charge is not refundable.

a dependent child of the student visa holder, or of that

partner, who is unmarried and has not turned 18.
AusAID or Defence sponsored students should contact AusAID
or the Department of Defence for procedures. It is not
necessary for you to complete this form.

How to nominate
Complete this form and send it, along with the documents you
are required to provide, to your dependant(s) overseas.
Your dependant(s) should complete form 157A Application for
a student visa and lodge it, together with this form 919
Nomination of student dependants and the documents you
have provided, at an Australian mission overseas.

What documents do you need to provide?

Fees may be subject to adjustment at any time. Visa Application

Charges may be subject to adjustment on 1 July each year. This
may increase the cost of a visa.
You can check the Visa Application Charge with your nearest
office of the Department of Immigration and Citizenship
(the department) in Australia, or from form 990i Charges, which
is available from the departments website
www.immi.gov.au/allforms/

Integrity of nomination
The department is committed to maintaining the integrity of
the visa and citizenship programs. Please be aware that if you
provide us with fraudulent documents or claims, this may result
in processing delays and possibly your nomination being
refused.

About the information you give

Certified or notarised copies of all pages of your passport,

including the page showing your current Student
(Temporary) visa and your personal details;
an original letter from your education provider stating:
the course you are studying
the duration of that course and anticipated completion
date
whether you are satisfying course requirements;
evidence of, and/or declaration of access to, funds to support
your nominated dependants:
original bank statements
an original letter from your financial institution confirming
the status of your account;
For details of evidence of funds required refer to the relevant
visa application document checklist which is available from
the departments website
www.immi.gov.au/students/checklists
evidence of your relationship with your nominated
dependants (for example, original marriage or birth
certificates);
evidence that adequate arrangements have been made for
the education in Australia of all your school aged dependants
(children who are unmarried and who have turned 5 years
of age, but have not yet turned 18 years of age), where the
proposed period of stay is more than 3 months;

The department is authorised to collect information provided

on this form under Part 2 of the Migration Act 1958. The
information collected will be used for assessing the eligibility of
your dependant(s) for a Student (Temporary) visa to travel to
and enter and/or remain in Australia, to monitor the conduct of
migration agents, and for other purposes relating to the
administration of the Migration Act.
The information collected might also be disclosed to agencies
who are authorised to receive information relating to adoption,
border control, business skills, citizenship, education, health
assessment, health insurance, health services, law enforcement,
payment of pensions and benefits, taxation, superannuation,
review of decisions and registration of migration agents. It will
also be disclosed to any agency of the Australian Government,
or of a state or territory, that is responsible for or otherwise
concerned with the regulation of education providers.
The information on this form, including the results of any tests
for Human Immunodeficiency Virus (HIV), will be used to
assess your health for an Australian visa. A positive HIV or other
test result will not necessarily lead to a visa being denied. Your
result(s) may be disclosed to relevant Australian Government
state and territory health agencies.

COMMONWEALTH OF AUSTRALIA, 2012

919 (Design date 04/12) - Page 1

In addition, the relevant registered education provider(s) may

be told whether or not your visa has been granted. The
collection, access, storage, use and disclosure by the department
of the information you provide in this form is governed by the
Privacy Act 1988 and, in particular, by the 11 Information
Privacy Principles. The information form 993i Safeguarding
your personal information gives details of agencies to which
your personal information might be disclosed. This form is
available from the departments website
www.immi.gov.au/allforms/ or from any office of the
department or Australian mission overseas.
The department is authorised under the Migration Act 1958, in
certain circumstances, to collect a range of personal identifiers
including a facial image, fingerprints and a signature from noncitizens, including from visa applicants. The department requires
personal identifiers to assist in assessing your identity. The
department is authorised to disclose your personal identifiers
and information relating to your name and other relevant
biographical data to a number of agencies including law
enforcement and health agencies and to other agencies who
may need to check your identity with this department. Where
the department obtains personal identifiers they will become
part of your official record with the department.
The department is involved in international information
exchanges with a number of countries, including the United
Kingdom, the United States of America, Canada and New
Zealand. These international information exchanges may involve
the sharing of personal identifiers, including facial images and
fingerprint data, collected by immigration agencies such as this
department. If, as a result of this sharing between countries,
there is a match with your personal identifiers, the department
will disclose your biographical data, copies of travel and other
identity documents or information from such documents, your
immigration status and immigration history (which may include
any immigration abuse and offences) and any criminal history
information relevant to immigration purposes. The purpose of
such disclosure would be to help confirm your identity and
determine if you have presented to the department and the
other agency under the same identity and with similar claims.
For more detailed information you should read information
form 1243i Your personal identifying information, which is
available from the departments website
www.immi.gov.au/allforms/ or from any office of the
department or Australian mission overseas.

Home page www.immi.gov.au

General Telephone 131 881 during business hours
enquiry line in Australia to speak to an operator (recorded
information available outside these hours).
If you are outside Australia, please contact
your nearest Australian mission.

Please keep these information pages for your reference

919 (Design date 04/12) - Page 2

COMMONWEALTH OF AUSTRALIA, 2012

Form

Nomination of student dependants

919

Please use a pen, and write neatly in English using BLOCK LETTERS.
Tick where applicable

Your details
1

10 Relationship status

Your family name in English

Family name

Muhammad

Given names

Ikhwan

Male

Sex

Married

Separated

Engaged

Divorced

De facto

Widowed

Never married or
been in a de facto
relationship

11 Your immigration file number (if known)

Female

Overseas
DAY

Date of birth

Place of birth

MONTH

YEAR

22-Jun-1988

In Australia

12 Details from your passport

A0906465

Town/city

Palembang

Passport number

Country

Indonesia

Country of passport Indonesia

DAY

Citizenship/Nationality

Indonesian

40 Cheltenham Street Highgate SA

POSTCODE

25-Jul-2011

Date of expiry

25-Jul-2016

Issuing authority/
Place of issue as
shown in your
passport

Your current Australian residential address

5063

MONTH

Date of issue

YEAR

Banda Aceh

13 Details of identity card or identity number issued to you by your

government (if applicable) eg. National identity card.
Note: If you are the holder of multiple identity numbers because you are
a citizen of more than one country, you need to enter the identity number
on the card from the country that you live in.

Address for correspondence

(If the same as your residential address, write AS ABOVE)

AS ABOVE

Identity number 1171092206880001

Country of issue Indonesia

POSTCODE

Office hours

(AREA CODE

After hours

(AREA CODE

Personal/private
mobile/cell

14 Give details of the Australian visa that you currently hold

Your telephone numbers

Visa label number

V 7

No

Fax number

< 1

Office of visa issue

Jakarta
DAY

Give details
(AREA CODE

If you were granted a visa without a label, give the 13-digit visa grant
number (as shown on the letter that notified you of visa grant).

+61449634049

Do you agree to the department communicating with you by fax, e-mail

or other electronic means?
Yes

Date of issue

MONTH

YEAR

14-May-2012

E-mail address ikhwan_june1988@yahoo.com

Note: If this application is refused, you will be notified by mail
COMMONWEALTH OF AUSTRALIA, 2012

919 (Design date 04/12) - Page 3

2. Name
in English

15 Give details of the course that you are currently studying

Name of your current course

Ethnic script

Master of Occupational Health and Safety Management

Relationship
to you

Name of the education provider or training body

The University of Adelaide

DAY

Course
duration

MONTH

YEAR

01-Jun-2012

DAY

MONTH

Date of birth (DAY/MONTH/YEAR)

Place of
birth

YEAR

to 31-Dec-2013

Citizenship/
Nationality

16 Do you have any applications before this department either in Australia

Is evidence of your relationship attached?

or overseas?
No

Yes

No

Yes

No

Yes

No

Yes

3. Name
in English

Give details

Yes

No

Ethnic script

Type of application

Relationship
to you

When did you lodge this application?

Date of birth (DAY/MONTH/YEAR)

Place of
birth

Where did you lodge this application?

Citizenship/
Nationality
Is evidence of your relationship attached?

17 Do you have:
adequate means to support yourself and your dependants?

4. Name
in English

No
Yes

Ethnic script

You may be asked to provide supporting documents

Relationship
to you

obtained health cover for your dependants?

Date of birth (DAY/MONTH/YEAR)

Place of
birth

No
Yes

Please provide evidence

Citizenship/
Nationality

enrolled any school aged dependants (that is, children who are unmarried
and who have turned 5 years of age, but have not yet turned 18 years
of age) who are included in this nomination, in a school in Australia?
No
Yes

Is evidence of your relationship attached?

5. Name
in English

Please provide evidence of enrolment, including

details of any school fees

Ethnic script
Relationship
to you

Members of the family unit

coming to Australia

Date of birth (DAY/MONTH/YEAR)

Place of
birth

18 Give details of members of the family unit who will be joining you in

Citizenship/
Nationality

Australia while you hold a student visa.

(Members of your family unit may include your partner and any
dependent children of you or your partner who are unmarried and have
not turned 18.)
1. Name
in English

Is evidence of your relationship attached?

If insufficient space, please attach a separate sheet

Fazia

Ethnic script
Relationship
Spouse
to you
Date of birth (DAY/MONTH/YEAR)
Place of
Banda Aceh
birth

01-Jul-1987

Citizenship/
Nationality Indonesian
Is evidence of your relationship attached?
919 (Design date 04/12) - Page 4

No

Yes
COMMONWEALTH OF AUSTRALIA, 2012

19 Overseas contact address of members of your family unit who will be

Declaration

joining you in Australia

WARNING: Giving false or misleading information is a serious offence.

In English

25 I declare that the information supplied on and with this nomination form
is complete, true and correct in every particular.
POSTCODE

Your signature

Ethnic script

DAY

Date

MONTH

YEAR

23-May-2013

POSTCODE

20 Overseas contact telephone numbers of members of your family unit

We strongly advise that you keep a copy of this nomination

and all attachments for your records.

who will be joining you in Australia

COUNTRY CODE

AREA CODE

NUMBER

Office hours

) (

After hours

) (

Personal/private
mobile/cell

Assistance with this form

21 Did you receive assistance in completing this form?
No

Go to Question 25

Yes

Please give details of the person who assisted you

Title:

Mr

Mrs

Miss

Ms

Other

Family name
Given names
Address

POSTCODE

Telephone number or daytime contact

COUNTRY CODE

Office hours

AREA CODE
) (

NUMBER
)

Mobile/cell

22 Is the person an agent registered with the Migration Agents Registration

Authority (MARA)?
No
Yes

Go to Question 25

23 Is the person/agent in Australia?

No

Go to Question 25

Yes

24 Did you pay the person/agent and/or give a gift for this assistance?
No
Yes

COMMONWEALTH OF AUSTRALIA, 2012

919 (Design date 04/12) - Page 5