About This Form: It Is the Responsibility of the Person Lodging This Application to Obtain

Statement under the Australian Passports Act Form B-11 2005 Application for an Australian travel document Australian Government

Department of Foreign Affairs and Trade General Declaration by Passport Applicant

This form must be completed and submitted with a passport application where required. Note: It is an offence under the Australian Passports Act 2005 to deliberately make a false or misleading statement. 1 Person lodging Detailsapplication of the Your full name person completing this form Your current address

2 Details Details of the Statement

3 Declaration Declaration by the I declare that the information I have given on this form is complete and correct and person completing that I am aware that the penalty for making a false or misleading statement either in this form writing or orally to obtain an Australia travel document is $110 000 or 10 years imprisonment, or both.

Signature Date DD/MM/YYYY Full name (please print)