Payment Reference No. ______

APPLICATION FOR WESTERN AUSTRALIAN GOVERNMENT STATE NOMINATION FOR A BUSINESS VISA

INVESTOR RETIREMENT VISA 405

Name:

Attached is my completed State Nomination Application form, including (a):

Copy of passport bio-data page

Completed Form 1249 https://www.border.gov.au/Forms/Documents/1249.pdf

Declaration

I declare that

·  All of the information contained in my application is correct;

·  I have assessed myself against the Department of Home Affairs 405 Investor Retirement visa criteria and believe I meet all the requirements; and

·  I will contact the Business Migration Centre upon settling in Western Australia to confirm my arrival and activities in the State.

______(Name of Applicant)

______(Signature of Applicant)

Dated (dd/mm/yyyy):

Migration Agent Declaration (if applicable)

As the appointed migration agent for the above named applicant I declare that

·  To the best of my knowledge the information contained in the application is correct;

·  I have assessed the applicant against the Department of Home Affairs 405 Investor Retirement visa criteria and believe he/she meets all the requirements; and

·  The applicant has read and understands the content of this application.

______(Name of Migration Agent)

______(Signature of Migration Agent)

Dated (dd/mm/yyyy):

Please Note: The Business Migration Centre reserves the right to request applicants, agents or representatives of applicants for State nomination to formally attest to the accuracy of the information contained in this application or its attachments.

Please send your application to:
Business Migration Centre
Small Business Development Corporation
GPO Box C111
PERTH WESTERN AUSTRALIA 6001 / Telephone: (+618) 6552 3300
Facsimile: (+618) 6552 3399
Email:

WESTERN AUSTRALIAN GOVERNMENT

STATE NOMINATION APPLICATION FORM

Family Name:

Given Names:

Gender: M / F Date of birth (dd/mm/yyyy):

Applicant’s Address:

Postcode:

Telephone: Facsimile:

Mobile:

Email address:

English language ability:

Details of any Australian visa held:

Passport number: Country of issue:

Date of issue of passport (dd/mm/yyyy):

Please attach copy of passport bio page and Australian Visa label
(if applicable) (a)

·  Have you applied for nomination from any other Australian State or
Territory government? Yes No

Name of State or Territory government (if applicable):

·  Are you using the services of a migration agent? Yes No

·  Migration agent name (if applicable):

Business name (if applicable):

Postal Address:

Postcode:

Telephone: Facsimile:

Mobile:

Email address:

STATEMENT OF ASSETS AND LIABILITIES – CURRENT YEAR

INVESTOR RETIREMENT VISA

Name: Date (dd/mm/yyyy):

Please provide details of assets and liabilities which you have held for at least the past two years. Please tick any assets or liabilities held in Western Australia.

NB: Currency must be in Australian Dollars www.oanda.com/currency/converter/

ASSETS / AUD $ / LIABILITIES / AUD $
Family Home / Home Mortgage
Investment Property / Investment Loan
Household Contents / Personal Loan
Motor Vehicle / Other Loans
Net Assets in Business / Other (Please List)
Superannuation
Cash at Bank
Term Deposits
Shares
Managed Investments
Other (Please List)
TOTAL ASSETS / $ / TOTAL LIABILITIES / $
NET ASSETS / $


INVESTOR RETIREMENT VISA CRITERIA

All State nomination applicants need to demonstrate they meet the minimum Department of Home Affairs criteria for the business skills visa they are applying for. Supporting documentation must be attached where indicated.

1.  Are you 55 years or older at time of application?

Yes No

2.  Do you have any dependants, other than your partner?

Yes No

3.  You must be able to make a Designated Investment into Western Australian Treasury Bonds for a period of four (4) years. Please select one of the following:

You will make a Designated Investment of A$750,000 and reside in the metropolitan region of Western Australia

You will make a Designated Investment of A$500,000 and reside in a regional area of Western Australia

4.  State the name and postcode of the area you plan to live in during your stay in Western Australia:

Suburb/Town: Postcode:

Postcodes – Regional / 6041 to 6044
6083 to 6084
6121 to 6126
6200 to 6799
Postcodes - Metropolitan / All other postcodes

5.  In addition to the Designated Investment, you must transfer additional assets to establish a lifestyle in Western Australia.

The minimum assets required, in addition to the Designated Investment, are at least A$50,000.

The total value of your net assets is A$ (as per the attached statement of assets and liabilities for the current year).

The total value of your net assets to be transferred to Western Australia (including Designated Investment and settlement/domestic arrangements) is A$ .

6.  You (or you and your partner combined) must have an annual income stream of A$65,000 (residing in a metropolitan area) or A$50,000 (residing in a regional area).

Please specify your total annual income: A$ (currency must be in Australian Dollars).

Please provide a summary of your annual income and its source (include interest from your proposed Designated Investment):

Income source Amount

A$

A$

A$

A$

A$

7.  Background information:

·  Have you ever visited Australia or Western Australia? If yes, when and for how long?

·  Do you have any family or friends in Australia? If yes, where are they located?
·  Why have you chosen to migrate to Western Australia as opposed to another State or Territory in Australia?
·  Explain why you have chosen your preferred location to live in WA, and have you conducted any research on the area?

Please include any additional information you would like to have considered in your application.

Note: Please ensure all questions have been completed and that supporting documents are attached. All documentation submitted for your State Nomination application will be retained by the State Migration Centre. Original documents are not required. Please submit copies of any original documents.

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405 Investor Retirement – Designed 04/14