| Heading and notes: | Form No. 152 in the top right corner. Standard Interim period heading. | 
| Message area: | 30 unnumbered boxes in six lines. | 
| Reverse side: | Blank. | 
| Colours (text & form): | Black on white. | 
| Size of form overall: | 171 × 198 mm. | 
Details of use and rarity.
| Form sub-number | Schedule number | Earliest recorded date | Rarity rating | 
| TO-3 | No schedule number. | 13 December 1912 at (Mel)bourne. | RRR |