Front of Form 30 - Type A
Name Age Male, Married Female, Single Occupation Object in coming to Canada Birthplace Citizenship Race Nat. Cert. No. Date Court State Attestor Last permanent address Street and No. Ever lived in Canada? Yes Address No Entered previously at Date Left Canada at Date Ever been refused admission into Canada Yes Where When No Money in possession belonging to immigrant $ If settler, value of effects $ Destined to Relative Friend or Employer Name Address Apparent condition of health R.R. tkt. issue No. Form From To Train No. or S.S. name Landing: Port 1st, 2nd or 3rd Class Date Steamship Objection to immigrant, if any Whether able to read or write? Time and port of last arrival in the United States Action taken