Form used in 1865, 1866, 1867, 1868 and 1869
Ports of embarkation Names of passengers Age of each Adult of 12 years & upwards Married M. F. Single M. F. Children between 1 & 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 Port at which Passengers have Contracted to Land