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QUINTUPLICATE
Form No. 200
Revised 5-15-18
AMERICAN RED CROSS
SERVICE APPLICATION FORM
Applicants for Nursing and Medical Service must accompany this form with special forms supplied by the Nursing Service and the Medical Service Bureaus
of the American Red Cross.
These questions must be answered fully or the application will not be acted upon.
Date
July 34th, 1920.
I. Name in full
Telephone No.
670
2. Permanent Address
Sant
(State)
3. Temporary Address, if any, to what date
(Number and Street)
(City)
(State)
4
(a) If any changes of residence since August I, 1914, give these in full with dates
I left Dallas
Texas July 9th, 1915 This is the only change I have made.
(b) What is your present business or profession? Surgical Murso in Texase
Name of firm or corporation with which associated
Sand
Duration of Service
three years.
Present Capacityead Nurse
Business Address
Sumbachio Fexas c/o Waxahacitic (City) Sanitarium.
(Number and Street)
(State)
5. Date of Birth
1892
Fab.
Place of birth
Peancott, Artison
(Year)
(Month)
(Day)
(b) If of foreign birth, when and where did you arrive in the United States?
6. If foreign born, give date and court of your naturalization
7. (a) Single, married or widower
Single.
(a) Number of Dependents
None.
(b) Full name of wife before marriage; or husband
(c) Birthplace of wife or husband
Nationality of wife or husband
(d) Birthplace and nationality of father of wife or husband
(e) Birthplace and nationality of mother of wife or husband
(f) Full name of father. Joha Toaley Cul away.
(g) Birthplace and nationality of father Albany Georgia, American.
(h) If father foreign born, whether naturalized, when and where
(2) Full maiden name of mother Sarah Ann Barton Mellillion.
(j) Birthplace and nationality of mother Procest Arkanona, American.
(k) If mother foreign born, whether naturalized, when and where
(1) Full name and nationality of paternal grandfather. John Collaway.
American.
(m) Full maiden name and nationality of paternal grandmother.
Lunior Huthis.
American.
(n) Full name and nationality of maternal grandfather.
Mathew MgMillian.
Aperican.
(o) Full maiden name and nationality of maternal grandmother.
Mary Elizabeth Goodlett.
American.
8.
(a)
What previous business or professional experience have you had, stating nature, places and principal dates
thereof; the names of the firms or corporations with which you were associated
I had one year
private nursing in Dallas Team. and Three years of Hospital work The Washing
achie Sanitarium is the only institution I have been associated with.
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Document data
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"ocrText": "QUINTUPLICATE\nForm No. 200\nRevised 5-15-18\nAMERICAN RED CROSS\nSERVICE APPLICATION FORM\nApplicants for Nursing and Medical Service must accompany this form with special forms supplied by the Nursing Service and the Medical Service Bureaus\nof the American Red Cross.\nThese questions must be answered fully or the application will not be acted upon.\nDate\nJuly 34th, 1920.\nI. Name in full\nTelephone No.\n670\n2. Permanent Address\nSant\n(State)\n3. Temporary Address, if any, to what date\n(Number and Street)\n(City)\n(State)\n4\n(a) If any changes of residence since August I, 1914, give these in full with dates\nI left Dallas\nTexas July 9th, 1915 This is the only change I have made.\n(b) What is your present business or profession? Surgical Murso in Texase\nName of firm or corporation with which associated\nSand\nDuration of Service\nthree years.\nPresent Capacityead Nurse\nBusiness Address\nSumbachio Fexas c/o Waxahacitic (City) Sanitarium.\n(Number and Street)\n(State)\n5. Date of Birth\n1892\nFab.\nPlace of birth\nPeancott, Artison\n(Year)\n(Month)\n(Day)\n(b) If of foreign birth, when and where did you arrive in the United States?\n6. If foreign born, give date and court of your naturalization\n7. (a) Single, married or widower\nSingle.\n(a) Number of Dependents\nNone.\n(b) Full name of wife before marriage; or husband\n(c) Birthplace of wife or husband\nNationality of wife or husband\n(d) Birthplace and nationality of father of wife or husband\n(e) Birthplace and nationality of mother of wife or husband\n(f) Full name of father. Joha Toaley Cul away.\n(g) Birthplace and nationality of father Albany Georgia, American.\n(h) If father foreign born, whether naturalized, when and where\n(2) Full maiden name of mother Sarah Ann Barton Mellillion.\n(j) Birthplace and nationality of mother Procest Arkanona, American.\n(k) If mother foreign born, whether naturalized, when and where\n(1) Full name and nationality of paternal grandfather. John Collaway.\nAmerican.\n(m) Full maiden name and nationality of paternal grandmother.\nLunior Huthis.\nAmerican.\n(n) Full name and nationality of maternal grandfather.\nMathew MgMillian.\nAperican.\n(o) Full maiden name and nationality of maternal grandmother.\nMary Elizabeth Goodlett.\nAmerican.\n8.\n(a)\nWhat previous business or professional experience have you had, stating nature, places and principal dates\nthereof; the names of the firms or corporations with which you were associated\nI had one year\nprivate nursing in Dallas Team. and Three years of Hospital work The Washing\nachie Sanitarium is the only institution I have been associated with."
}