| Heading and notes: | No form number. Electric Telegraph, Victoria in curved line above crest. |
| Message area: | Blank. |
| Reverse side: | Regulations and Conditions (14 listed). Also form details [300,000 | 2 | 67] |
| Colours (text & form): | Red on blue paper. |
| Size of form overall: | 171 × 214 mm. |
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Details of use and rarity.
| Form sub-number |
Schedule number | Earliest recorded date | Rarity rating |
| TO-3 | None | 9 April 1868 at Maryborough. | RRRR |