| Occupation as written | no occupation |
| Standardised occupation | XX00: Other - Other |
| Application received | 4 Sep 1911 |
| Application status | Approved |
| Official | JAM |
| Date of approval or denial | 5 Sep 1911 |
| If rejected, why? | |
| Birthplace as written | Bohemia |
| Modern country | Czechia |
| Age on application | 65 |
| Age on arrival in Australia | 36 |
| Port of Departure | Bohemia |
| Port of Arrival | Brisbane |
| Date of arrival | 1 Oct 1882 |
| Name of ship | Stephen |
| Voyage | Stephen (1882-10-01) |
| Address in Australia | Towerie Rd., c/o Mr. C. Redmond, Gowrie Rd., Toowoomba |
| Address State | Queensland |
| Time at address | 18 years |
| Previous address 1 | Grosmburgee |
| Address State | Queensland |
| Time at address | 11 years |
| Married | Widow | |
| Children | Yes | 2: female living in Toowoomba |
| Name of reference | Joseph James Scully |
| Occupation of reference | Justice of the Peace (Queensland) |
| Marginalia description | |
| Police report attached | No |
| Link to other applicant | |
| Literate | No |
| Reason | N/A |
| Other information |