Formulaire utilisé entre 1874 et 1878
(Disponible en anglais seulement)
Port of embarkation
Names of passengers
Adults
Age
M.
F.
Children between 1 and 14
Age
M.
F.
Infants
M.
F.
Occupation
Nationality
Births at Sea
Deaths
Places in the Dominion of Canada or United States to which Passengers are bound
Remarks