Front of Form 30A - Type B
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