| Occupation as written | House Duties |
| Standardised occupation | DS00: Domestic service - Domestic duties |
| Application received | 16 Aug 1911 |
| Application status | Approved |
| Official | JAM |
| Date of approval or denial | 31 Aug 1911 |
| If rejected, why? | |
| Birthplace as written | Bialoslick, Russia |
| Modern country | Russia |
| Age on application | 48 |
| Age on arrival in Australia | 41 |
| Port of Departure | London |
| Port of Arrival | Melbourne |
| Date of arrival | 25 Nov 1904 |
| Name of ship | Grosser Kurfust |
| Voyage | Grossen Kurfurst (1904-11-25) |
| Address in Australia | 338 Cardigan St., Carlton |
| Address State | Victoria |
| Time at address | 5 months |
| Previous address 1 | 109 Palerston Street, Carlton |
| Address State | Victoria |
| Time at address | 1 years, 3 months |
| Previous address 2 | 117 Palmerston St |
| Address State | Victoria |
| Time at address | 4 years |
| Previous address 3 | 138 Hur Street, Fitzroy |
| Address State | Victoria |
| Time at address | 1 years |
| Married | Yes | |
| Children | Yes | 6: 3 males and 3 females, all living at home |
| Name of reference | Archibald George Shanks |
| Occupation of reference | Constable of Police (Victoria) |
| Marginalia description | |
| Police report attached | No |
| Link to other applicant | |
| Literate | No |
| Reason | N/A |
| Other information |