| Occupation as written | Housewife |
| Standardised occupation | DS00: Domestic service - Domestic duties |
| Application received | 20 May 1914 |
| Application status | Approved |
| Official | |
| Date of approval or denial | 20 May 1914 |
| If rejected, why? | |
| Birthplace as written | Richmond, Victoria |
| Modern country | Australia |
| Age on application | 26 |
| Age on arrival in Australia | None |
| Port of Departure | None |
| Port of Arrival | None |
| Date of arrival | None |
| Name of ship | None |
| Address in Australia | 28 Peel Street, Ballarat |
| Address State | Victoria |
| Time at address |
| Previous address 1 | Melbourne |
| Address State | Victoria |
| Time at address |
| Previous address 2 | Geelong |
| Address State | Victoria |
| Time at address |
| Married | Yes | |
| Children | Yes | 3: all male |
| Name of reference | H S Simmons |
| Occupation of reference | Justice of the Peace (Victoria) |
| Marginalia description | |
| Police report attached | No |
| Link to other applicant | |
| Literate | Yes |
| Reason | N/A |
| Other information | Ada to AH, 14 May 1914, p.5: husband, S J Haseqawa from Tokyo and 'is a throughbred Japanese and has not been naturalized' |