first name:

middle name:

last name:

maiden name (where applicable):

name of father:

name of mother:

name(s) of siblings:

full name of spouse:
(include spouse’s maiden name, if applicable):

means of transport: Select one Travelled by sea Travelled by air Combination of both air and sea travel

name of ship: (where applicable)

name of your home town in the netherlands:

select one: Select one Schoolchild/student Qualified professional Business proprietor Qualified tradesperson Unqualified tradesperson Unskilled worker Domestic duties Retired Other

(If you chose “other” above, please clarify)

spoken english: Select one Minimal Not bad Good

written english: Select one Minimal Not bad Good

first job/position in tasmania:

eventual career in tasmania:

your favourite story about adjusting to life in tasmania:

any other comments about your experiences as a dutch immigrant in tasmania:

We can arrange to record your story on video for storage in the Channel Heritage Museum. If you select “Yes” below, we will contact you to make arrangements for the recording.

If you have any further comments or instructions on how your information is used/stored, please indicate your wishes here. Perhaps you may wish to keep part or all of the information you give confidential for a period of time. If so, just let us know. Your wishes wil be respected.

any further comments/instructions:

Your privacy will be respected. Contact details are purely for us to contact you if we need clarification on any of your responses above, or to arrange a time to record your story. Your contact details will not be included in any public record.

phone: (required field)

email: