Formulaire utilisé entre 1909 et 1921
(Disponible en anglais seulement)
1. No. of Passengers.
2. No. of S.S. Contract Ticket
3. Amount of Cash in $
4. Name in full
Age of adults.
5. Male.
6. Female.
Children under 14 years.
7. Male
8. Female.
9. Married, Single, or Widowed.
10. Have you ever been in Canada before?
If so
11. When.
12. Where.
13. How Long.
14. Do you intend to permanently reside in Canada?
15. Are you able to read?
16. Are you able to write?
17. Country of Birth
18. No. of Passengers.
19. Race of People.
Destination
20. Post Office.
21. Province.
22. What was your occupation in country from which you came?
23. What is your intended occupation in Canada?
24. Have you ever worked as farmer, farm labourer, gardener, stableman,
carter, Ry, surfaceman, navvy or miner?
If so
25. Which
26. How long
27. When
28. Religious Denomination.
29. Travelled inland on
30. Initials of civil examiner.
31. No. of Passengers