Recto du formulaire 30 - Modèle C)
(Disponible en anglais seulement
1. Name
2. Last permanent address
Street and No.
3. Age
Male Married Widowed
Female Single Divorced
Occupation
4. Birthplace
5. Citizenship Race or people
6. Nat. cert. No. Date
Court State
Attestor
7. Able to read? Write? Language?
8. Religious denomination
9. Ever lived in Canada?
Yes Address
No
Entered previously at Date
Left Canada at Date
10. Why left Canada
11. Ever been refused admission into Canada
Yes Where?
No
12. Money in possession belonging to immigrant $
13. If settler, value of effects $
14. Object in coming to Canada
15. Destined
Relative
Friend, or
Employer
Name
Address
16. Apparent condition of health
17. R.R. Tkt. issue No. Form
From To
Train No. or S.S. name
18. Landing:
Port Date
Steamship
1st, 2nd or 3rd Class
19. Time and port of last arrival in the United States
20. Mentally defective Sec. 3 (a)
Yes
No
21. Ever had tuberculosis Sec. 3 (b)
Yes
No
22. Physically defective Sec. 3 (c)
Yes
No
23. Anarchist, etc. sec 3 (n) (o)
Yes
No
24. Objection to immigrant, if any