Form used between 1925 and 1935
1. Line 2. Family name, given name 3. Relationship Age 4. M. 5. F. 6. Single, married, widowed or divorced 7. Country and place of birth 8. Nationality (country of which a citizen or subject) 9. Race or People If in Canada Before 10. Between what periods 11. At what address 12. Ever refused entry to or deported from Canada? 13. Do you intend to reside permanently in Canada? 14. Can you read? 15. What Language 16. By whom was passage paid 17. Line Occupation 18. What trade or occupation did you follow in your own country? 19. What trade or occupation do you intend to follow in Canada? Destination 20. If destined to relative, friend or employer state which and give name
and full address. If not joining any person in Canada, give the address
in Canada to which you are going 21. Give name, relationship and address of your nearest relative in the
country from which you came. If a wife or children are to follow you later
to Canada, give names and ages Have you or any of your family ever been 22. Mentally defective 23. Physically defectives 24. Tubercular Passport 25. Number, place and date of issue 26. Money in possession belonging to passenger 27. Travelling inland on 28. Action taken and civil examiner