F WM
__________ 184 __E_R_A_.M__g.i§______.__E._1AM_______RRRA9.J;_-_
(F inn) (Middle) (Last) .
2. ADDRESS (Print) J’-
_________________________ E awn; Kw W$odhl¢$+
(Number and «rector R F D num er) (Tint (County)
3. TELEPHONE 4. Am: IN YEARS 6. COUNTRY OF
szmsmr
33
_____________ L534
9. ADDRESS or THAT PERSON
_______________ E:
(Number and Street or R
10. EMPLOYER’ S NAME
REGISTRATION CARD
1). s. s. Form 1 16—17105 ‘;:m.é.m [/M .....
(over) (Regina-n c'l Ska-cure)