| Occupation as written | None |
| Standardised occupation | XX00: Other - Other |
| Application received | 1 Jan 1911 |
| Application status | Unknown |
| Official | |
| Date of approval or denial | 14 Mar 1911 |
| If rejected, why? | incomplete. a new form D sent to her but not returned |
| Birthplace as written | Platzk, Poland (Polish) |
| Modern country | Poland |
| Age on application | 72 |
| Age on arrival in Australia | 34 |
| Port of Departure | Platzk |
| Port of Arrival | Adelaide |
| Date of arrival | 4 Apr 1873 |
| Name of ship | Golden Len |
| Voyage | Golden Len (1873-04-04) |
| Address in Australia | Hontifin Home, St. Kilda Road, St Kilda |
| Address State | Victoria |
| Time at address |
| Previous address 1 | Sydney |
| Address State | New South Wales |
| Time at address | 14 years |
| Previous address 2 | Adelaide |
| Address State | South Australia |
| Time at address | 12 years |
| Previous address 3 | Melbourne |
| Address State | Victoria |
| Time at address | 12 years |
| Married | Yes |
| Children | No |
| Name of reference | Joseph Levi |
| Occupation of reference | Justice of the Peace (Victoria) |
| Marginalia description | |
| Police report attached | No |
| Link to other applicant | |
| Literate | No |
| Reason | N/A |
| Other information |