1100 - Department of Immigration & Citizenship

State/Territory nomination
Form
1100
Please use a pen, and write neatly in English using BLOCK LETTERS.
Tick where applicable
✓
Client file or Transaction Reference Number (TRN) (if known)
1
Details of nominee
Nominee’s full name
Details of the approved state/territory
agency
Family name
9
Nominating state/territory
Given names
2
Date of birth
DAY MONTH YEAR
10
Name of authorising agency
3
4
Citizenship
Number of migrating dependants
11
Do you agree to the department communicating with you by
telephone or e-mail?
No
5
Visa data
Which visa subclass is this nomination for?
Yes
Phone
E-mail address
Give details
(AREA CODE )
Subclass 176
Subclass 886
12
Signatory on behalf of nominating state/territory government agency
Subclass 475
Full name
Subclass 487
Position title
Occupation data
Signature
6
Nominated occupation (as stated on Applicant’s skills assessment)
Date
DAY MONTH YEAR
7
ANZSCO code
We strongly advise that you keep a copy of the nomination and
all attachments for your records.
8
Off-list nomination data
You need to complete the following box for off-list nominations
This nomination is number
of 100
for the Program Year
1100 (Design date 07/11) - Page 2
© COMMONWEALTH OF AUSTRALIA, 2011