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Return to Canadian Records

Form 30A (Original)


S.S. __________________ CLASS _______ DATE OF SAILING _____________________

                              DECLARATION OF PASSENGER TO CANADA

1. Name ________________________________________________ Age _______________

2. Sex _____ Are you married, single, widowed or divorced? _________________________

Are you accompanied by husband or wife? If so, give details of husband or wife ___________________________________________________________________________

3. Present Occupation ___________ Intended Occupation __________________________

4. Birthplace ____________________ Race or People ______________________________

5. Citizenship ___________________ Religion ____________________________________
                                                                            (if Protestant, state denomination)

6. Object in going to Canada __________________________________________________

7. Do you intend to stay permanently in Canada? __________________________________

8. Have you ever lived in Canada? ______________ If you have, give Canadian address ___________________________________________________________________________

Port of first arrival in Canada __________________________Date ____________________

Port of last departure from Canada _____________________ Date ____________________

9. Why did you leave Canada? _________________________________________________

10. Money in possession belonging to passenger __________________________________

11. Can you read? __________ What language? __________________________________

12. By whom was your passage paid? ___________________________________________

13. Ever refused entry to or deported from Canada? ________________________________

14. Destined to? ____________________________________________________________


(If known relative, friend or employer {1} state which, and if relative, give relationship {2}
give his or her name and Canadian address {3} If not joining any person in Canada, give
your own Canadian address)

15. By which Canadian railway are you travelling to destination? ______________________

16. Nearest relative in country from which you came _______________________________

(name) (relationship)

(give full address of such relative)

17. Are you or any member of your family mentally defective? ________________________

Tubercular? _______________ Physically defective? _______________________________

Otherwise debarred under Canadian Immigration law? ______________________________

(Before answering question 17, see the prohibited classes named in Immigration Booklet 30A
which be handed to you by booking agent)

I declare the above statements are true. I am aware that a false statement constitutes
misrepresentation, and that the penalty is a fine, imprisonment or deportation.

Signature of passenger _______________________________________________________

I hereby declare that the above is the signature of passenger, and that I have handed passenger
a copy of Immigration Booklet 30A

Signature of booking agent _____________________ of ____________________________



NAME ________________ AGE __________

SS ________________________________ (date stamp)

CLASS ______________________________




Is Passengers ticket cash or prepaid __________________________________________

Date and number of ticket issued _____________________________________________

Place ____________________ Name of agent __________________________________

If prepaid order, give following information regarding exchange of the order

Place ___________________________________________________________________

Date exchanged ___________________________________________________________

Name of agent ____________________________________________________________

Passport number ___________________ Serial No. ______________________________

Issued by ________________________________________________________________

Date of issue ________________ at __________________________________________

Passport designates holder a national or citizen of ________________________________



(stamp - Canadian Port Agent)



Action taken (detained/admitted) Cause ____________________________

(signature) ____________________________

(examining officer)




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