Front of Form 30 - Type C
1. Name 2. Last permanent address Street and No. 3. Age Male Married Widowed Female Single Divorced Occupation 4. Birthplace 5. Citizenship Race or people 6. Nat. cert. No. Date Court State Attestor 7. Able to read? Write? Language? 8. Religious denomination 9. Ever lived in Canada? Yes Address No Entered previously at Date Left Canada at Date 10. Why left Canada 11. Ever been refused admission into Canada Yes Where? No 12. Money in possession belonging to immigrant $ 13. If settler, value of effects $ 14. Object in coming to Canada 15. Destined Relative Friend, or Employer Name Address 16. Apparent condition of health 17. R.R. Tkt. issue No. Form From To Train No. or S.S. name 18. Landing: Port Date Steamship 1st, 2nd or 3rd Class 19. Time and port of last arrival in the United States 20. Mentally defective Sec. 3 (a) Yes No 21. Ever had tuberculosis Sec. 3 (b) Yes No 22. Physically defective Sec. 3 (c) Yes No 23. Anarchist, etc. sec 3 (n) (o) Yes No 24. Objection to immigrant, if any