Recto du formulaire 30A - Modèle B
(Disponible en anglais seulement)
1. Name
2. Age
Male Married Widowed Occupation
Female Single Divorced Intended occupation
3. Birthplace
4. Citizenship
5. Religion
6. Object in coming to Canada
7. Ever lived in Canada?
Yes Address
No
Port of previous entry Date
Port of departure Date
8. Why left Canada
9. Money in possession, belonging to immigrant $
10. Able to read?
11. What language?
12. By whom was passage paid?
13. Intend to remain permanently in Canada?
14. Ever previously rejected or deported from Canada?
Yes
No
15. Destined to
Relative
Friend
Employer
16. Canadian Railway Routing
17. Nearest relative in country from whence passenger came
18. Mentally defective Sec. 3 (a)
Yes
No
19. Ever had tuberculosis Sec. 3 (b)
Yes
No
20. Physically defective Sec. 3 (c)
Yes
No
21. Anarchist, etc. Sec. 3 (n) (o)
Yes
No