Recto du formulaire 30 - Modèle A
(Disponible en anglais seulement)
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