1. Name - first, middle, last
2. Permanent home address - #, street or R.F.D. #, city or town, county , state
3. Age in years
4. Date of birth - month, day, year

RACE (check the appropriate one)
5. White     6. Negro     7. Oriental     INDIAN (check the appropriate one)   8. Citizen     9. Non-citizen
 

U.S. CITIZEN (check the appropriate one)
10. Native Born
11. Naturalized
12. Citizen by father's Naturalization before registrant's majority
 

ALIEN (check the appropriate one) 13. Declarant 14. Non-Declarant

15. If not a citizen of the U.S., of what nation are you a citizen or subject?
16. Present occupation
17. Employer's name
18. Place of employment or business - #, Street or R.F.D. #, City or town, county, state

Nearest Relative
19. Name
20. Address - No., Street or R.F.D. No., city or town, county, state

Signature or mark of Registrant

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