4 Questions to be answered [crossed out 'asked'] by each applicant for a Eugenic Certificate [centered double score] [crossed out 'Referring to the applicant himself. A'] Your name in full, place and date of your birth, your address, your occupation. Maiden surname of your mother; full name and address of your father, his occupation. Have you undergone a physical examination as to fitness for any branch of the public service? If so, state particulars & date. Can you refer to any physical competition of which records are accessible, in which you were ranked distinctly higher than the average of your competitors? If so, give not more than three of the most notable instances. Have you performed any feats that were [crossed out 'are'] distinctly beyond the powers of men of the same [crossed out 'your'] age [crossed out 'at the time'] and of such training to yourself? Give particulars of not more than 3 of the most notable instances. Have you been classified in any important literary examination, whether at school, or college, for a public [end]