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Address <br /> <br />Phone No. <br /> <br />Are you over age 187 Yes ~ <br /> <br /> Last First <br />, .½o fi4 l /.Vci, <br /> StreetCity <br /> <br />State ] <br /> <br />Middle <br /> <br /> Zip <br /> <br />Are you under 65? Yes l~ No <br /> <br />EMPLOYMENT: <br />Present Employer <br /> Ad.ms <br /> <br />Working Hours ~:b <br /> <br />Could you leave work to resl~ond toga fh-e?. <br /> <br />Could you obtain written authorization to leave work.'? <br /> <br />Yes No <br />Yes No <br /> <br />EDUCATION: <br /> <br />High School <br /> <br />College or <br />Trade-School <br /> <br />Other Special <br />Training <br /> <br />Name of School <br /> <br /># of Years Attended <br /> <br />No applicant testing positive for nicotine shall be accepted for membership. <br /> <br /> <br />