Formulaire utilisé en 1866, 1867, 1868 et 1869
(Disponible en anglais seulement)
Port of Embarkation
No. of Contract Ticket
Names of Passengers
Age of each Adult of 12 years and upwards
Married
M.
F.
Single
M.
F.
Children between 1 and 12 years
M.
F.
Infants
M.
F.
Profession, Occupation or Calling of passengers
English
Adults
Children
Infants
Scotch
Adults
Children
Infants
Irish
Adults
Children
Infants
Other parts
Adults
Children
Infants
Port at which Passengers have Contracted to Land