Men's Rights Agency
CONFIDENTIAL INFORMATION - Page 1 of 3

CONFIDENTIAL INFORMATION To be completed and returned by Level 1 Applicants (Print or 'save to file' to print later)

YOUR PERSONAL DETAILS

Date:.................

Mr/Mrs/Ms............

FirstNames.......................................................................................
(Please underline name you wish to be addressed by)

Surname..........................................................................................

Address............................................................................................

City/Suburb......................................... State............. P/C .................

A.H.Tel:........................................Bus.Tel:.......................................

Mobile.......................................... Fax:..............................................

Email ................................................

Postal Address:.................................................................................

City...........................................State ...............Postcode..................

Date of Birth....................Country of Birth:..............................

Australian Citizenship Date..............................

Is English your main language:..........................

Do you need an interpreter needed.....................

Language required ...........................................

Occupation/Qualifications....................................................................

Employer............................................................................................

YOUR EX-PARTNER/WIFE DETAILS

First Names..............................................................

Surname........................................ MaidenName...............................

Address............................................................................................

City/Suburb.................................... State........... Postcode................

A.H. Tel:................................... Bus.Tel:.........................................

Mobile........................................Fax:..............................................

Date of Birth:.......................Country of Birth:.....................................

Australian Citizenship date: ...............................

Occupation/Qualifications...................................................................

Employer................................................................................. .........

Name of Solicitor...............................................................................

Address & Tel:..................................................................................

MARRIAGE/RELATIONSHIP DETAILS

If a MARRIAGE complete details below
	Date of Marriage	_ _/_ _/_ _
	Are you still living together	..........................
	Or separated but living under the one roof	..........................
	Date of Separation	_ _/_ _/_ _
	Date of Divorce	_ _/_ _/_ _
	Place of Divorce	...............................

 

If a DEFACTO relationship complete details below
	When did you first start living together	_ _/_ _/_ _
	When did you stop living together	_ _/_ _/_ _
	Or are you separated but living under the one roof	......................
	Or did you never live together	......................

                                                                                                        continue to Children's details Pg2
continue to Property/asset details etc Pg 3
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Men's Rights Agency P/L ACN 063 925 566
A non-profit organisation helping men and their families

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