\r 
Are they prepared to nominate you?... 
Have you at any time resided in Australia or New Zealand? If so, when 
ind where?....... 
Have you any preference for a particular State in Australia®........ 
If you cannot be accepted for the State you prefer, are you prepared to 
settle elsewhere in Australia?....- 
Are you prepared to engage in Agricultural work on arrival?.... reno 
Have you interviewed or communicated with a Passenger Agent? If so, 
vive name and address........... 
Have you previously communicated with the Australian Migration and 
Settlement Office or with an Employment Exchange? If so, when?............eet 
When do you desire to sail?....... 
(The Director of Migration has entered into contracts with all the 
sustralian Passenger Lines, so passengers must clearly understand that 
vhile he will give every reasonable consideration to desires they may express 
ho travel by any particular steamer, he must reserve entire liberty to give 
hem passaces by such Line as best fits in with his arrangements.) 
Undertaking to engage in Farm Work in Australia. 
vereby declare that if I am accepted by the Deputy Director, Migration 
and Settlement, Australia House, Strand, I will engage in Farm Work upon 
my arrival in Australia, and 1 fully understand that the wages current for 
this class of work are 10s. to 15s. per week and keep. Should I during the 
first 12 months seek any employment other than Farm Work, or should I 
during the first two years leave Australia, I agree to repay the full amount 
of the financial assistance granted to me as an assisted passage under the 
Empire Settlement Act. 
[ declare all the above statements to be true and if my application for un 
assisted passage 1s accepted and approved I agree that it is subject to 
sancellation by the Government at any time and that the approval imposes 
upon the Government of Australia no legal obligation to take me to Aus- 
tralia; and that if the cancellation of approval or passage is exercised by 
she Government, I shall have no claim against the Government or its 
officials for any damages, loss, expenses, compensation or otherwise except 
a refund of passage or landing money supplied by me in the case where 
such cancellation arises through no wrongful act or default on my part. I 
further understand that persons who are found to have contracted con- 
tagious diseases before landing in the Commonwealth of Australia are 
‘able to be returned to Great Britain and that my admission to the Common- 
wealth of Australia js, notwithstanding the aforementioned approval for an 
assisted passage, subject to the provisions of the Immigration Restriction 
Act. 
Signature of Applicant........ eee Daterceiiiiniiiiiinnnn, 
{This form must be signed by the applicant personally; a signature 
bv another person on his behalf will not suffice.)