Family History Application Form
1 Department of Aboriginal Affairs
Ground Floor, 151 Royal Street, East Perth WA 6004
PO Box 3153, East Perth WA 6892
Ph: 1300 651 077 Fax: (08) 6551 8088
www.daa.wa.gov.au
Please fill in as much as you can
Title - Mr / Mrs / Ms / Prof / Dr (please circle)
Family name .........................................................................................................
Christian name(s) ................................................................................................
Maiden name ........................................................................................................
Aboriginal name ..................................................................................................
Date of birth .................... /......................./ .........................
Place of birth …………………………....................................................................
To protect the confidentiality of personal records, applicants must provide
evidence of identification. Please attach a photocopy of one of the following:
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Driver’s licence
Passport
Medicare card
Centrelink card
Health Care card
A letter confirming identification from a Justice of the Peace (JP).
Current address ...................................................................................................
..................................................................................Postcode .............................
I declare that the information I have provided is correct and / or accords with
what I have been told.
Telephone (home) .....................................................................
(work) .....................................................................
Applicant’s signature .........................................................................................
(mobile) ..................................................................
Date ………......... /..................... / ..................
Email ........................................................................ Fax .....................................
Information sought (please tick box / boxes)
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Please forward completed form to:
□ Mother’s side.
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Family Information:
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Family History Card/s (censored) - A summary of a Personal File/s created
PO Box 3153
pre-1948, and/or extracts from a restricted Administration File/s pre 1972.
EAST PERTH WA 6892
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Father’s side
Department of Aboriginal Affairs
Tindale, Birdsell or Epling genealogy of 1939, 1953 and 1954, or
Elkin genealogy of 1930.
OR
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Ancestral Tindale photographs.
Fax to: (08) 6551 8088
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Ancestral origins / links to land.
Email: [email protected]
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Other - please specify e.g. (date of birth)………………………………………….
Family History Application Form
2 Your mother’s family
Your father’s family
Mother’s name …………...........................................................□ Living / □ deceased
Father’s name .....................................................................□ Living / □ deceased
Mother’s maiden name ……..........................................................................................
Father’s Aboriginal name ........................................................................................
Mother’s Aboriginal name .............................................................................................
Father’s place and date of birth ...............................................................................
Mother’s place and date of birth ...................................................................................
Father’s sisters and brothers ...................................................................................
Mother’s sisters and brothers .......................................................................................
………………………………………………………………………………………………
..………………………………………………………………………………………………...
Grandmother’s (mother’s mother) name ..................................□ Living / □ deceased
Grandmother’s (father’s mother) name……………....……...□ Living / □ deceased
Grandmother’s maiden name .......................................................................................
Grandmother’s maiden name ..................................................................................
Grandmother’s Aboriginal name ...................................................................................
Grandmother’s Aboriginal name ..............................................................................
Grandmother’s place and date of birth .........................................................................
Grandmother’s place and date of birth ....................................................................
………………………………………………………………..………………………………...
……………………………………………………………….………………….…………..
Grandfather’s (mother’s father) name ......................................□ Living / □ deceased
Grandfather’s (father’s father) name ...................................□ Living / □ deceased
Grandfather’s Aboriginal name .....................................................................................
Grandfather’s Aboriginal name ................................................................................
Grandfather’s place and date of birth ............................................................................
Grandfather’s place and date of birth ......................................................................
………………………………………………………………………………………….
……………………………………………………………………………………..………..
Your own family
Your contribution to our search
Your brothers and sisters (starting with the eldest)
To assist us in our efforts to locate information about you and your family could
you please provide us with the names of those places where you, your parents
and your grandparents lived and worked in the following decades:
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1960s........................................................................................................................
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1950s........................................................................................................................
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1940s........................................................................................................................
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1930s........................................................................................................................
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