[Page 1.]

Form No. 22

COMMONWEALTH OF AUSTRALIA.

IMMIGRATION ACT 1901-1912.

[Stamped in black ink, right top corner: 'CUSTOMS & EXCISE', 'SOUTH AUSTRALIA', '901981', '15-3-21'.]

[Handwritten:] Adelaide

[Handwritten:] March 17^th 1921

Sir,

I beg to apply for a Certificate under the Immigration Act 1901-1912, Section 4 (B), and Regulations, and I forward herewith a Statutory Declaration in support of my application.

I wish to visit Hong Kong. China [location handwritten] for twelve [number handwritten] months.

I attach two [number handwritten] Certificates of my character, and six unmounted photographs of myself (three full face and three profile).

I undertake and intend not to bring with me or to introduce into the Commonwealth on my return to the Commonwealth any relative who is not possessed of an unexpired or unrevoked certificate excepting him or her from the provisions of paragraph (a) of section 3 of the above Act, and I also undertake and intent not to be directly or indirectly privy to the bringing to or introduction into the Commonwealth of any such relative.

If my application is granted, please intimate the fact to me at the above address.

Yours faithfully,

[Handwritten signature:] Sym Choon[.]

[Addressed to:] THE COLLECTOR H.M. CUSTOMS,

[Handwritten:] at Port Adelaide. S. Aus.

[Footer in small bold text:] NOTE.- The Statutory Declaration should set out the length of residence in Australia, and should verify all documents accompanying the application, and should be in the form required by the "Statutory Declarations Act 1911."

A.206/12.13.-C.16303.

[Page 2.]

[Stamped in black ink, right top corner: 'CUSTOMS & EXCISE', 'SOUTH AUSTRALIA', '901981', '15-3-21'.]

[Heading:] COMMONWEALTH OF AUSTRALIA.

[Heading in large bold text:] STATUTORY DECLARATION.

[Small text:] (1) Name of declarant. [End small text.]

I, (1) Sym Choon [name handwritten]

now residing at 237 Rundle St East [address handwritten]

do solemnly and sincerely declare that the answers to the following questions are true:-

[Dividing line.]

[This portion of the page is divided into 2 columns. The questions are in the left column. The responses are handwritten in black ink in the right column.]

1. Of what nationality are you? …

1. China

2. Where were you born, and when? …

2. Hong Kong

3. When did you first [word underlined] come to Australia? …

3. about 28 years ago

4. Where have you lived since you came to Australia?

[Small text, underlined:] (State places and period of residence in each.)

4. Unley and Adelaide 9 or 10 years at Unley rest of time lived at Adelaide

5. Have you ever been absent from Australia since your original arrival? If so, state –(a) on how many occasions: (b) for what period on each occasion, giving date of departure and return.

5. No

6. What is your present occupation? …

6. Green grocer and Importer of Chinese goods.

7. What other occupations (if any) have you carried on since you came to Australia?

7. and importing & selling Groceries[.]

[Dividing line.]

And I make this solemn declaration by virtue of the Statutory Declarations Act 1911 conscientiously believing the statements contained therein to be true in every particular.

[Small text at left margin.] (2) Signature of declarant.

(2) [Handwritten signature:] Sym Choon

Declared at Adelaide [location handwritten] the seventeenth [number handwritten] day of March 1921 [date handwritten].

Before me,

[Small text at left margin.] (3) Person before whom declaration is made.

(3) [Handwritten:] William Charlick

[Small text at left margin.] (4) Title of person before whom declaration is made (a).

(4) [Handwritten:] Justice of the Peace

[Small text:] (a) This Declaration may be made before a Police, Special, or Stipendiary Magistrate: a Justice of the Peace ; a Commissioner for Affidavits ; or a Commissioner for Declarations.

[Bold, centred:] NOTE. – Any person who wilfully makes a false statement in a Statutory Declaration is guilty of an indictable offence, and is liable to imprisonment, with or without hard labour, for four years.