Formulaire utilisé entre 1904 et 1908
(Disponible en anglais seulement)
No. of Passengers. Number of Railway Order. Amount of Cash. To be filled in by Immigration Agent at Port of Landing. Name of Passenger. Age of Adults. Children under 14 years of age. Able to Read Write Married or Single. Profession, Occupation, or Calling of Passengers. Nation or Country of Birth. Counties in British Isles from which Passenger came. Births at Sea. Deaths at Sea. Place of ultimate destination of Passengers excepting "Tourists and
returned Canadians," who are to be so described.