ANNEX No. 2. DEPARTMENT OF HEALTH, CAanada. (This Certificate must be presented at the Canadian Port of Entry.) Place of Examination.......... (This Certificate is valid only for four months from date of issue to date of Embarkation.) ANNEX No. 3. DEPARTMENT OF IMMIGRATION AND COLONIZATION, GOVERNMENT OF CANADA. 5. Married or Single or Widower......... 5a. Age of Wife if living......... 6. No. of Children (State age and sex of each.) 7. Will your Wife and Children accompany you?... 8. If not, what provision are you making for them in this country? 9. A medical certificate from a Doctor on the Official Roster may be required; therefore state exact condition of mental and physical health of yourself and individual members of family: 10. Have you or has any member of your family suffered at any time from insanity, epilepsy or tuberculosis in any form, or any infectious disease? 11. If you or any member of your family has any physical defect, give particulars of it 12. Have you or has any member of your family ever been treated in an Institution or Home?.. If so, give particulars... 13. State intended occupation in Canada... 14. Where? 15. Is such occupation assured?............ 15a. By whom?..... 16. Have you lived in Canada or elsewhere Overseas?...... (a) Where? (b) Between what dates?. 17. Can you pay your own fare to final destination in Canada?.. (a) What money will you possess in addition, at time of landing in Canada? § 18. If relatives or friends are providing a home, give name, address and relationship, and state how long they have been in Canada... 19. How many years have you farmed?.......... What kind of farming?.. Can you milk?............ Can you plough?.......... How many horses can you handle?.................................. What experience with other live stock?. 19a. Are you capable of harnessing, hitching and driving horses? 19b. Are you capable of operating the simpler farming implements, such as cultivators, discs, harrows and rollers?........ 20. Are you working on a farm?.......... If not, state last occupation.............. 21. Give names and addresses of two farmers for whom you have worked, and how long with each. If you have not been employed on a farm state so, and give names and addresses of your last employers. Name..... Name..... Address...... 22. Give name and address in the British Isles of parents or nearest living relative (state relationship).... 23. When do you wish to leave for Canada? (If possible give name of steamer, date of sailing and class by which you intend to travel, and rail destination in Canada)... 24. If you are in communication with a Shipping or Booking Agent, give his name and address........ Signature... (To be filled in by Canadian Government Agent.) 25. Origin of business 6. Name, relationship and address of nearest relative in the British Isles 7. Present occupation..... Intended occupation.. 8. To whom destined overseas.. (Give full name and address, and state if friend, relative or employer.) 9. Name of Steamer by which you are sailing..... 10. Date of sailing.......... Name of Booking Agent........ Address... 11. Class of ocean travel (Cabin or Third)....... 12. Have you ever resided in Canada? If so, for how long?. 13. When did you last leave Canada and for what purpose?..... 14. Have you any friends or relatives in the United States of America? If so, where?.. 15. If accompanied by children, give the following particulars: 17. I hereby certify that the applicant is personally known to me and (Indicate what you know of the applicant's character, industry and honesty and whether you believe the above questions have been correctly answered.) 18. Signature.. Address........ (To be signed by one of the following, to whom the applicant is personally known: A member or official of any Banking firm established in the United Kingdom, any Mayor, Minister of Religion, Registered Medical Practitioner, Barrister-at-Law, Solicitor, Notary Public, Magistrate or Justice of the Peace.) In cases where the Medical Examiner is unable to describe the applicant as being in good health, he should state under "Remarks" the exact nature of the defect which he finds and whether it is of a temporary or permanent nature. Any disablement received on Active Service or otherwise should also be noted and commented on. To avoid needless hardship the Medical Examiner is particularly requested to satisfy himself that the applicant is in every way a fit subject to pass a thorough medical examination, as applicants are liable to rejection both at the ports of embarkation and at the port of arrival. The presence of Pediculi or Nits should be noted hereon. In the case of women, if pregnant, please note the fact in "Remarks" column, and state number of months. 3. Has she ever been in a Sanatorium or other institution or attended thereat for the treatment of Tuberculosis?.......... 4. Any sign of disease of the Genito-Urinary Organs.. 5. Nervous System and Mental Condition...... State whether she has ever suffered from Mental Disease, or Epilepsy, or been treated in any institution of any kind for Remarks Age Height Weight... Having read and made myself conversant with the instructions contained in Form KA, supplied me, I certify that I have this day examined the above-named, and am, therefore, of the opinion that she is in ................................health and of............constitution. She is not suffering from any mental or bodily defect which in my opinion would unfit her for earning her own living as a..... ...in Canada. I hereby certify that the information supplied by me to the Medical Examiner is correct in every particular: Signature of applicant which must be made in the presence of the Medical Examiner Instructions to Persons being Examined. 1. For children a separate statement or medical schedule is required. 2. Under no circumstances will any Medical Certificate be accepted unless duly certified by a Medical Referee who is on the Official Roster and whose name is given to you with this form. 3. It must be fully understood that the fees for Medical Examination must be paid by yourself. The Maximum Scale of Fees is as follows: 10s. 6d. for each adult of 16 years or over; 2s. 6d. for each child under 16 years of age accompanied by parents or guardians with a limit of £1 6s. for the examination of any one family, not more than two children to be charged for under the age of 16 years. Children unaccompanied, 10s. 6d. each, irrespective of age. 4. This Medical Certificate is for your assistance and guidance but does not in any way guarantee your admission to Canada. The Medical Examination that admits you to Canada takes place at the Canadian port of arrival. If this Certificate does not show that you and your dependents are in good mental and physical health, correspond at once with your nearest Canadian Government Emigration Agent and defer booking your passage until advised whether or not your difficulties can be cleared up. Officials whom you may see or write to. London.-Director of European Emigration for Canada, The Canadian Building, Trafalgar Square, S. W.1. Canadian Government Emigration Agents at: 48, Lord Street, Liverpool. 139, Corporation Street, Birmingham. 52, Baldwin Street, Bristol. Canada Chambers, Museum Street, York. 310, High Street, Bangor (Wales). 107, Hope Street, Glasgow. 33, Academy Street, Inverness. |