| Heading and notes: | Form No. E.T. 28 (?). DELIVERY FORM above Crest which is spanned by ELECTRIC TELEGRAPH ___ WESTERN AUSTRALIA. | 
| Message area: | 33 boxes in 11 lines. | 
| Reverse side: | Blank. | 
| Colours (text & form): | Black on pink. | 
| Size of form overall: | 287 × 207 mm. | 
| Size of datestamp box: | 28 × 42 mm. | 
|  | IWC-DO-1. London via Broome to Cue, WA. Has the LRD for the scarce Cue Telegraph Office oval Characteristics: 
 
 Only recorded used example of this delivery form. | 
Details of use and rarity.
| Form sub-number | Schedule number | Earliest recorded date | Rarity rating | 
| DO-1 | None. | 10 January 1901 at Cue, WA. | RRRRR (used) |