Recto du formulaire 30 - Modèle B
(Disponible en anglais seulement)
Name
Last permanent address
Street and No.
Age
Male Married Widowed
Female Single Divorced
Occupation
Birthplace
Citizenship Race or People
Nat. Cert. No. Date
Court State
Attestor
Able to read? Write? Language?
Religious denomination
Ever lived in Canada?
Yes Address
No
Entered previously at Date
Left Canada at Date
Why left Canada
Money in possession belonging to immigrant $
If settler, value of effects $
Object in coming to Canada
Destined to
Relative
Friend or
Employer
Name
Address
Ever been refused admission into Canada
Yes Where?
No
Apparent condition of health
R.R. tkt. issue No. Form
From To
Train No. or S.S. name
Landing:
Port Date
Steamship
1st, 2nd or 3rd Class
Time and port of last arrival in the United States
Object to immigrant, if any