Application to visit Australia

PLEASE PRINT

BOTH SIDES OF FORM TO BE COMPLETED

1. LAST NAME	2. FIRST AND MIDDLE NAMES	3. NAME IN ETHNIC SCRIPT (if applicable)
Darby	Elva
4. PREVIOUS NAMES (including maiden name)	PARTICULARS OF BIRTH
Mayo	Date 12 / 29 / 11 Month Day Year
	Town/City	Country
	Clarendon, Ark.	USA
6. SEX	7. PRESENT CITIZENSHIP	8. MARITAL STATUS	9. OCCUPATION
Male Female	USA	Single Married Widowed Divorced Separated	Housewife
10. PERMANENT HOME ADDRESS
Route 2, Box 218	Thompson Station, Tennessee	USA 37179	Home 615-794-6888 Business
Street and No.	Town/City, State	Country, Zip Code	Telephone Number
11. PASSPORT DETAILS
Number J1884744	Place of Issue New York, NY	Date of Issue 6 / 15 / 78 Month Day Year	Valid Until 6 / 14 / 83 Month Day Year
12. PURPOSE OF INTENDED VISIT TO AUSTRALIA
If visit for business purposes provide brief details by letter from your Company. Sightseeing Business See Relatives Medical Treatment To accompany husband to scientific meeting
13. CONTACT ADDRESS IN AUSTRALIA (If visiting relatives state relationship and if visiting for business state Name of Business Contacts). Prof. R. Lovell, Australian Associated Brewers, University of Melbourne, Dept. of Medicine, Royal Melbourne Hospital, Victoria 3050
14. LENGTH OF STAY (Indicate No. of Days, Weeks, Mos.)		15. PROPOSED DATE OF DEPARTURE FROM HOME FOR AUSTRALIA
Days [ ]	Weeks [ ]	Months [ ]	10 / 16 / 79 Month Day Year
16. DETAILS OF YOUR PREVIOUS VISITS TO OR APPLICATIONS TO ENTER AUSTRALIA FOR ANY PURPOSE. (If no previous visit or application state 'nil'). nil

Form M48 (1-79) IR U.S.

(PLEASE TURN OVER!)

17. PARTICULARS OF FAMILY MEMBERS ACCOMPANYING (If on this applicant's passport and included in this application)

Full Name	Relationship to Applicant	Date of Birth (Month/Day/Year)	Sex

18. DECLARATION.

I DECLARE THAT NEITHER I NOR ANY ACCOMPANYING DEPENDENT FAMILY MEMBER
LISTED IN THIS FORM:

Is suffering from any dangerous contagious disease such as tuberculosis; is suffering or has suffered
from any mental illness; is addicted to narcotics or is a trafficker in narcotics, has a criminal record;
has been deported from any country

I ALSO DECLARE THAT

I have sufficient funds to support myself and all dependent members of my family during the
period of the visit

I and any accompanying dependent family members will, if granted visitor visas, travel to Australia
on fully paid return passage tickets or tickets for travel to an onward destination outside Australia;
will produce these tickets on arrival in Australia and will retain them while in Australia.

I and any accompanying dependent family members will not engage in employment or in formal
studies in Australia; will not seek authority to settle in Australia and will leave Australia at the end
of the authorised visit period.

I FURTHER DECLARE THAT the particulars provided by me in this application are true in every
detail.

Elva Maye Darby

9/25 / 197 79

Signature of Applicant

NOTE:

If you are unable to complete this declaration in respect of any matter, you should cross
out the item in question and sign the declaration as amended. You should then submit
with the application a statement outlining the reasons why you were unable to declare in
respect of the deleted item.

Date of Issue

Validity

Period Stay

Special Conditions

Entry

Single/Multiple

Source: https://www.industrydocuments.ucsf.edu/docs/skcv0228