Immigration Application for the United States of America

 1-Full name: 

 2-Age:     

 3-Sex: 

 4-Married or Single?         

 5-Occupation:   

 6-Able to read or write?  

 7-Nationality:  

 8-Last residence:   

 9-Seaport for landing in the United States:   

10-Final destination in the United States:  

11-Do you have a ticket through to this destination?  

12-Did you pay your own passage?   

12a-If no, who or what paid it? 

13-How much money do you have with you?

14-Are you going to join a relative?  

14a-If yes, what relative (name and address):                

15-Were you ever in a prison or an almshouse, or supported by charity? 

16-Are you a polygamist (married to more than one person)?  

17-Are you under contract, expressed or implied, to perform labor in the United States? 

18-What is your condition of health mentally and physically? 

19-Are you deformed or crippled? 

19a-If so, from what cause?

20- In a paragraph, why do you want to live in the United States?