Census of Population of Ireland, 1971
1. Name and surname_____
If self employed, state nature of business in which engaged
If a farmer, state the area and total ratable valuation of the farm on which working
If a farm worker, state the area of the farm on which working
If out of work, state the name, address and nature of the business of last employer.
State age at which full-time education ended____
Vocational, technical, or commercial: ___ years
University or higher technical: ____ years
[The following questions should be answered in respect of each private household and of the house, flat or rooms occupied by that household. These questions need not be answered in respect of private households living in caravans or other mobile dwellings.]
State the area and ratable valuation of all agricultural holdings (if any) in the state, of which persons usually resident in the household are the rated occupiers. Land held under the eleven months system or in conacre or in commonage should not be included.
Area in statute acres _____
Valuation (land and buildings): ______ pounds
 Rented unfurnished, other than from local authority
 Rented furnished or part furnished
 Being acquired from local authority under a purchase or vested cottage scheme
 Owner occupied (including cases where loan or mortgage repayments are being made)
 Occupied free of rent (caretaker, company official, etc.)
If the house, flat or rooms are rented, state the rent (inclusive of rates and ground rent) and strike out periods which do not apply.
Pounds _______ (per week, month or year)
Pence _______ (per week, month or year)
If the house, flat or rooms are rented unfurnished other than from a local authority, did the letting commence before 1961?
 Before 1860
 Between 1860 and 1899 inclusive
 Between 1900 and 1918 inclusive
 Between 1919 and 1940 inclusive
 Between 1941 and 1960 inclusive
 1961 or after
 Water tap, outside the building only, connected to public main
 Water tap, inside the building, connected to private source
 Water tap, outside the building only, connected to private source
 No piped water supply
If "Yes", is this bath or shower shared with another household?
 Dry closet
 Chemical closet
 No toilet or closet
Is the toilet or closet inside the building?
Is the toilet or closet shared with another household?