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eas wait Sar EES f: re As 2a 3 PREVIOUS EMPLOYMENT RECORD FOR FIVE YEARS (ALL time must be accounted for. Lf unemployed more than 30 days give exact datea,) ——————-. WAME & ADORESS AF FORMER EMPLOYERS . wean yo ry whY 010 YOU LEAVE? Name of Las Present Eq: loyer: — amt. “ CF 2 Sueet. Cat a en Cite” a Sa hm ily a Titate Preceding Erploy =. all gntantiatarl oh A Seeer Cis Preceding Ermolayry ? Sweet, Ce Fa Ste - Citwhetn Piper emcee Stare eek, | Preceding Employer: c- Street Case OF EMERGENCY, nOTiFy . ADORESS. . . Pont WUMBER - , siete Ter, 4. ROL AAG MPH SIO - LETC . - ot HEALTH HISTORY ; e Yoo Re .. Yes Ng . Yoo Na : ; _ CD High Btood Pressure ( (],Stomach Uicer j [Xf Kidney Diseese Convulsions (fis, epilepsy) oO Syphillis °* 0 Rheumatic Fever [1] (Xj Permanent defect os : Heart Disease Of Gonorrhea - OO BJ Asthma - . result of disesne of sccident. C3 GY Tebercuioses C1 PY Diaderes . OEY Rack Trouble Cy OH Using Drugs Head of spinal injuries (severe) Other uinesses ar iniuzies, opesacions, ot dospital admissions - “ — ee nn a eetet aecrhdch, Lage ty LS Ra SE ee Ene yn a a ene: een re ee oy red tubs Firauan is porrect and Aps-heen entered by oy own hend. | unideserend and agive of tam granted ni made Sy meon thes lc etcon shall of tee consiute good and sulficucnt Cause for my dismieeai. betas wy aor creeteraing that 2 Sorat PNP eme nt gk Contingent upon receipt of satislactory relerens ee. t. : Pauw ce te cetiaty fet aratemencscber | have made ebout the arare of my past ond present Reelth are « . , a Signasuie <= a . - . = rf eAe, Cee" 2D wOl ae te Bee ee me . RECORD OF PHYSICAL FINDINGS (Gen oe Goet — bas 0 Roo Hegel. Teighe : : Heod. . ‘sto wantance Cwathuat glasses) Right 20/.._ (with gisssee af worn) Lele 70/___ ° widence of aiseaselor injucy. Raghe 2 Left. Cofm Vision _ A PORE, “ven Heating, 20 ft, Raghe ear, £20, Lelieur —. . 20. Disease of anpary Ee Margit, Throat .. : Thorax: Meme oe eee — UW organic disease is present, is at fully compenssred? . Hhoad poeasure {sitding). Systolic Pe Deastolic Pelalge, melore erercase ___ cg i Alter 2 inutes rest Westie ee ne ie Abdomen. * oe Seats ae. : Abnormal masacs __ Tenderness teria. Fes tt a0, where? a : Truse? Genite-Jrinary: Neate . Urethrai Discharge Retienes: Rhoannerg wo... nee : . Rw LW _ Pepolasy wo 1. Light RB L x Accomedadon: RK L_ Knee Jerks: Right, Noemat " Inceresed CA ent . ; Lefi: -Notmai os Increased : Abseat. Catremitioniiineiaper — Lowes _ Spine **Laborataiy fern gs of tenes age indicated: Urine: Sp. Ge. . . Alb. . Sug. : Other . id Ae . ; . DOCTOR'S CERTIFICATE. tee . _— SG This wis te. comcfy that have chin dav eramioed the above applicant in accordance with SI9L.2, end the physica! eramiaation were paenbed by che Motor CacriesSaiety Regulations, Revision of 1952 of the Interstare Commerce Comaiasion, and that | tied Bott ayaa aes onze hee wearing glasses, Disqualified Quahiined under seid cules .. ‘ : 8h Dawe arpt on tie onomy Olle & complered praminaiion form lar thes pereoa. Opironel racepr with ICC enamineuena. - sere nd Address Crete Ream nang Leen 2