35

D.—3

This "Form of Application" must be torn off from the first.Sheet, properly filled in and signed, folded so as to leave the Printed Address outside, and returned to this Office without delay. Form of Application. To tue Agent-General for New Zealand. Sir,— I hereby apply for a free passage to the Province of , New Zealand, for myself and the other persons named below; and I hereby declare that the statements contained in this paper are true, that I am of good character, and that I go to the Colony intending to work for wages in my calling ; and I hereby pledge myself to conform to the regulations for the voyage, and not to leave the ship until she arrives in . [And I hereby agree to pay the sum of £ in cash, for ship outfit mentioned in Clause XII.] I am, Sir, (Signature.) (Residence.) , (Date.)

Persons for whom this Application is made. The Christian and Surnames, in full, of the persons on whose behalf this application is made, must be entered here, together with all the other particulars required.

Enclosure 4 in No. 40. EMIGRATION TO NEW ZEALAND, UNDER THE CONDUCT OF THE GENERAL GOVERNMENT.

The above Applicant offers to pay £ in cash towards his outfit cost, and to sign Promissory Notes for £ payable to Her Majesty Queen Victoria We hereby certify that we have known the above-named person [s] for years.; that we believe him [her, them] to be sober, honest, industrious, and of good character, and that he [she, they] is [are] free from any bodily or mental defect likely to impair his [her, their] efficiency as good labourers. We also believe that he [she, they] really have not the means of paying, in cash, a larger part of the passage money than tho above-named sum, and is [arel deserving of the assistance he [she, they] seeks. We also believe that the above statement as to relationship, age, county, occupation, <&c, is true. (To be signed by two or more respectable householders of the Applicant's parish, one of whom should be Applicant's employer.) (Address and date.) I hereby certify that I have examined the above-named Applicant [and his wife and children] ; that, to the best of my knowledge and belief, he [she, they] are in good health, and free from any bodily deformity or mental defect likely to impair his [her, their] efficiency as labourers. I also certify that he [she, they] have all had the small-pox, or been vaccinated, and is [are] entirely free from any disorder usually considered infectious or contagious. (To be signed by a Physician or Surgeon.) (Address and date.)

Christian and Sur- Relation- ■,, a . _. „ , • Married or Age. name in lull. ship. o- i r Single. County where born, and where Occupation, living lately. Name, Address, and Oecupatioi of present Employer, and hoi long employed by him. If this application be approved, some certificates of character will b< be duly signed before the approval will be finally co: forwarded, which must ifirmed.

Certificate) required in the ci ;e of 'he following Pe; •sons applying for Free Passages : — Christian and Surname in full. Relationship. Whether Married or Single. Age. County where born, and where living lately. j Occupation, j Name, Address, and Occupation of Employer, and how long employed by him.