Document 7MNykqG0GVo3qm0pnL3LLYYjR

T ii 0 H ft 1 I>OS 2 ii oxo ">a 0-9 n S? r >2i5 *S * Zn a o C yo - ox oi O'* nz n-< 5* 2s C->4 r IS I? i (A _n *o* So9 >s nxiH o *3 |q Ss ? a > o m -< 0n % 3 X S* is* 3 m A szo* Si 0> zz Q * -O 3 ENVELO-FILE \ SPECIAL INFORMATION T .........................................................'MW iji,ili"liliiPajiiili.iiif'*iT^ffniii n..... . CYWI 4-001371 APPLICATION FOR EMPLOYMENT DO NOT WRITE IN THIS SPACE 2 -Date. M/j c GzeotZ Dept.. Print Name. -I - I1 ___________ Foreman. Job Title- Address. ^ / IV C C /V| A K C t-h OA Cxo Initial k k i i'J - I ^ Rate____ 5t. & No. City Stat* Towel___ XGl___ Started__ Phone__ ^ Married Date of Birth_______^ Soc. Sec. No._ Q Single Q Widowed i~~j Divorced U. S. Citizen?__^ ^ 1 v AJ Height- ^ 7 --Weight--{ Any record of convictions?- Q ______Are You Physically Handieapped?__=ki. .For what offense?. .How?. Have you friends or relatives in our employ?--hsLQ. in an emergency, whom shall we notify?. _LWoci> Nome -Who?____________ C^ftog. ^ hi. Address Phone .How related?. Grade School A~ A/1 jA EDUCATION .Years Attended-- k-- GroHiiote? Y^ ^ Data left /? 5 3 High School. (\ 0 0-6-Othr Tq Mq Xi r&cd. j ShA/i .-Years Attended. _______ Graduate?Dote Left .Years Attended____ l______Graduate? > C S .Dote left ^ "V EMPLOYER. Mc^'T-C <2 EXPERIENCE Y _________ From (date) I f (o 5 Jo. n 70 Address. CLO j .. i/\J. C~tlArl4-A. . R.& .City_ C-lJrJ __________State What was your job?. l)&UiM^A^3tC .Salary. Why did you leave?. > ko t-\J EMPLOYER.________ ______From (date). Jo. Address_____________ .City. . State. What was your job?. .Salary. S Why did you leave?. EMPLOYER________ Address. What was your job?. .From (date). City. Jo. .State. .Salary. Why did you leave?. EMPLOYER________ Address. What was your job?. .From (dote). .CHy. Jo_ .State. .Salary. Why did you leove?. Armed Forces Serial No--i.S-------.s< .cjh-------------- What kind of work do you do best?. AuV .Length of Service. .Second Best?____ READ OVER THE DATA YOU HAVE GIVEN AND MAKE CERTAIN ALL THE REQUESTED INFORMATION HAS BEEN ACCURAtaY AND COMPLETELY SUPPLIED. .p If additional space is needed, use reverse side. Signature--------- . ----------------------- CONFIDENTIAL INFORMATION REDACTED CYWI 4-001372 N14539.01 .r* WEINZIMMER CLINIC 1211 South Cicero Avenue PHYSICAL EXAMINATION Company. Applicant Preamt Employe* Re-employment --U-- ion flta-examiaatioa Previous Injuries, Operations or Diseases Name <j <^y Date. Nature Work < <2 7- ,/Address /,//' ^ J~n Race (,) 7 7Height Weight /^^-^Age Marital Status Deformities from Injuries or otherwise VISION Without Glasses Right Eye 20 Left Eye 20/- Physical Gr^e-, A____ BS1C_____D. Best ultimate Defects determining grading: Signed in presence of Medical Examiner Employee UP/?, Signed. elects correctable by: Croi'Kic Boainrea Turin*-* CONFIDENTIAL INFORMATION REDACTED Form IS CYWI 4-001373 N14539.02