(1) Name in Full: ~ Age in years: ~
(2) Home Address: ~
(3) Date of Birth: ~
(4) Are you (1) Natural born citizen (2) a naturalized citizen (3) an alien (4) or have you declared your intention (specify which) ~
(5) Where were you born? ~
(6) If not a citizen, what country are you a citizen or subject? ~
(7) What is your present trade, occupation or office? ~
(8) By whom employed? ~
Where employed? ~
(9) Have you a father, mother, wife, child under 12 or a sister or brother under 12, solely dependent on you for support? (specify which) ~
(10) Married or single (which)? ~ race (specify which) ~
(11) What Military service have you had? Rank Branch Nation or State: ~
Do you claim exemption? ~
specify grounds: ~
I affirm that I have answered above answers and that they are true: Signature

REGISTRARS REPORT

(1) Tall, medium or short (specify which) ~
(2) Color of eyes? ~ color of hair? ~ bald ~
(3) Has person lost arm, leg, hand, foot or both eyes or is he otherwise disabled? (specify how) ~
I certify that my answers are true, that the person registered has read his own answers, and that I have witnessed his signature, and that all of his answers of which I have knowledge are true, except as follows:

~
signature of registrar
Precinct: ~
City or County: ~
State: ~
Date of Registration: ~