Hebrew Immigrant Aid Society, Boston, Massachusetts

              Form A-2213—Boston
APPLICATION FOR A CERTIFICATE OF ARRIVAL No..
and
PRELIMINARY FORM FOR A DECLARATION OF INTENTION
U. S. DEPARTMENT OF LABOR
NATURALIZATION SERVICE
Report on Standard Form 1046
List No  	
For use in searching records of arrival:
RECORDS EXAMINED RECORD FOUND
Card index     Place	
Index books     Name  	
Manifests 	
Date   Manner 	
Use Form 161 in issuing
certificate of arrival on this
application.
(Signature of person making search)
TO THE APPLICANT: Do not write above this line.    Read carefully and follow the instructions on last page hereof
Take or mail this to
Date  , 19
DISTRICT DIRECTOR OF NATURALIZATION, June   21
Young's Hotel,
Boston, Mass.
certificate of arrival snowing my lawful entry for
permanent residence in the United States of America, to be used in filing my declaration of intention in the _  	
Court at  and herein submit a statement of facts to be used as a basis for such declaration.
(City or town) 
There are inclosed with this application, as required by law and the instructions herein, my original Immigrant Identification
Card No.  (see Statement No. 10), two photographs of me each of which I have signed, and postal money order
the sum of $5, made payable to the order of the "Commissioner of Naturalization, Washington, D. C," in
payment for the certificate of my arrival.
I arrived in the United States at 
under the name of 
on the vessel 	
 (If otherwise than by vessel, show manner of arrival)
I have been absent from the United States since that date, as follows	
May 5th 1907 left on
Additional facts to aid in locating a record of my arrival:
1. I have  used another name in this country.    (If so) It was   	
I used that name because         	
2. The full name of the person shown on my steamship ticket was 
3. I was born in 
4. My mother's maiden name was  
5. (If a married woman) My maiden name was    	
6. My last foreign residence was  
(Country)
The place where I took the ship or train which landed me in the United States was  
(7. The ticket on which I came to this country was bought at 
 (Country)
8. (If arrival by ship) Name of steamship line was    	
first, second, or third cabin    I arrived as a passenger, stowaway, seaman, member of crew,
or otherwise 
14—2622 (StatTwhich, giving particulars) [OVER]