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RED CROSS BADGE NUMBER
AMERICAN RED CROSS
17177
NURSING SERVICES
MILITARY SERIAL NUMBER
L
ANNUAL QUESTIONNAIRE - 1945
e
CHECK IF YOUR LAST NAME HAS CHANGED
NAME (Last, first, middle)
TELEPHONE NO.
to
IF MARRIED, GIVE MAIDEN Veta NAME Blanche
HUSBAND'S NAME
PERMANENT ADDRESS (Street, city, zone, county, state)
B
8.Vitnano Hospital, Kndville
PRESENT ADDRESS (Street, cl/ty, zone, county, state)
mairan county Lowa
-
48, Vituano Hoskital Kundville
NAME AND ADDRESS OF NEAREST RELATIVE OR FRIEND IN THE UNITED STATES
mairon RELATIONSHIP country Darna
mus Laura E. markley west Paint Illenous
mother
DATE OF BIRTH (Month, day, year)
Single
Married
Widowed
Divorced
nov. 29-1892
Separated
WHAT LANGUAGES DO YOU SPEAK?
YES
NO
English
HIGH SCHOOL GRADUATE
NAME OF COLLEGE OR
DEGREE OR
UNIVERSITY ATTENDED
LOCATION
INCLUSIVE DATES
DIPLOMA
MAJOR
ARE YOU CURRENTLY
YES
NO
REGISTERED IN (State)
ARE YOU CURRENTLY A MEMBER OF THE AMERICAN
YES
NO
REGISTERED?
Illinais
NURSES' ASSOCIATION?
PRESENT EMPLOYMENT If not employed, check
POSITION TITLE (H.N., P.D., inst., staff nurse, etc.)
SERVICE (Medicine, surgery, etc.)
Repatered nurse
NAME OF HOSPITAL OR ORGANIZATION BY WHOM EMPLOYED
numoprychintic CITY runing STATE
u.8. Vetuans Hospital
Knerville
gorra
HEALTH
IF OTHER THAN GOOD, SPECIFY NATURE AND ANTICIPATED DURATION OF DISABILITY
good
VOLUNTEER SERVICE
The purpose of the following statements is to identify the nurses who can be counted upon to respond to a cal
to participate in a Red Cross chapter program. Please check the "Yes" box only if you are willing and able to
serve if called on vithin the next 12 months.
NAME AND ADDRESS OF THE CHAPTER IN WHOSE JURISDICTION YOU EXPECT TO LIVE FOR THE NEXT 12 MONTHS
KNOXVILLI
chAp.
palk Country chapter 312 T lysics Bedy Dec 20pr YES YA NO
1. Teach home
YES
NO
(t tend an instructors' training program, 1f offered. (Funds are available for
nursing classes
training home nursing instructors. See local chapter.)
2. Serve in case
YES
NO
only in home community
Attend disaster institutes, if
YES
NO
of disaster
In other communities
offered, in preparation for service
3. Teach nurse's
YES
NO
4. Accept membership on chapter com-
YES
NO
5. Assist with other chapter
YES
NO
aide classes
mittee should services be needed
programs, as needed
If you have not answered "Yes" to any of the questions listed under VOLUNTEER SERVICE, do you anticipate that
YES
NO
you will be able to serve at some time in the future?
IF UNABLE TO SERVE, GIVE MAJOR REASONS-
here
DATE am employed the Veterans administration Hosfital and hoge to remain
9
SIGNATURE
august 17-1945
Veta Blanche Markley
YOUR FALUE AS A RED CROSS NURSE DEPENDS ON YOUR ABILITY AND WILLINGNESS TO SERVE AND YOUR PAITHPULNESS
KEEPING US INFORMED OF YOUR ADDRESS. PLEASE FILL IN THIS QUESTIONNAIRE AND RETURN IT PROMPTLY TO the
COMMITTEE NAMED BELOW.
ATTENTION
Fill in committee name and address before sending questionnaire to nurseRecruitment
Committee
SECRETARY
Polk County Chapter ARC
NURSE RECRUITMENT
Les
112 Flyon
COMMITTEE
Des Moines, - Iowa
78504M
FORM 1045 Rev. July 1945
Page data
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- Type
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Document data
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"ocrText": "M\nar\nK\nRED CROSS BADGE NUMBER\nAMERICAN RED CROSS\n17177\nNURSING SERVICES\nMILITARY SERIAL NUMBER\nL\nANNUAL QUESTIONNAIRE - 1945\ne\nCHECK IF YOUR LAST NAME HAS CHANGED\nNAME (Last, first, middle)\nTELEPHONE NO.\nto\nIF MARRIED, GIVE MAIDEN Veta NAME Blanche\nHUSBAND'S NAME\nPERMANENT ADDRESS (Street, city, zone, county, state)\nB\n8.Vitnano Hospital, Kndville\nPRESENT ADDRESS (Street, cl/ty, zone, county, state)\nmairan county Lowa\n-\n48, Vituano Hoskital Kundville\nNAME AND ADDRESS OF NEAREST RELATIVE OR FRIEND IN THE UNITED STATES\nmairon RELATIONSHIP country Darna\nmus Laura E. markley west Paint Illenous\nmother\nDATE OF BIRTH (Month, day, year)\nSingle\nMarried\nWidowed\nDivorced\nnov. 29-1892\nSeparated\nWHAT LANGUAGES DO YOU SPEAK?\nYES\nNO\nEnglish\nHIGH SCHOOL GRADUATE\nNAME OF COLLEGE OR\nDEGREE OR\nUNIVERSITY ATTENDED\nLOCATION\nINCLUSIVE DATES\nDIPLOMA\nMAJOR\nARE YOU CURRENTLY\nYES\nNO\nREGISTERED IN (State)\nARE YOU CURRENTLY A MEMBER OF THE AMERICAN\nYES\nNO\nREGISTERED?\nIllinais\nNURSES' ASSOCIATION?\nPRESENT EMPLOYMENT If not employed, check\nPOSITION TITLE (H.N., P.D., inst., staff nurse, etc.)\nSERVICE (Medicine, surgery, etc.)\nRepatered nurse\nNAME OF HOSPITAL OR ORGANIZATION BY WHOM EMPLOYED\nnumoprychintic CITY runing STATE\nu.8. Vetuans Hospital\nKnerville\ngorra\nHEALTH\nIF OTHER THAN GOOD, SPECIFY NATURE AND ANTICIPATED DURATION OF DISABILITY\ngood\nVOLUNTEER SERVICE\nThe purpose of the following statements is to identify the nurses who can be counted upon to respond to a cal\nto participate in a Red Cross chapter program. Please check the \"Yes\" box only if you are willing and able to\nserve if called on vithin the next 12 months.\nNAME AND ADDRESS OF THE CHAPTER IN WHOSE JURISDICTION YOU EXPECT TO LIVE FOR THE NEXT 12 MONTHS\nKNOXVILLI\nchAp.\npalk Country chapter 312 T lysics Bedy Dec 20pr YES YA NO\n1. Teach home\nYES\nNO\n(t tend an instructors' training program, 1f offered. (Funds are available for\nnursing classes\ntraining home nursing instructors. See local chapter.)\n2. Serve in case\nYES\nNO\nonly in home community\nAttend disaster institutes, if\nYES\nNO\nof disaster\nIn other communities\noffered, in preparation for service\n3. Teach nurse's\nYES\nNO\n4. Accept membership on chapter com-\nYES\nNO\n5. Assist with other chapter\nYES\nNO\naide classes\nmittee should services be needed\nprograms, as needed\nIf you have not answered \"Yes\" to any of the questions listed under VOLUNTEER SERVICE, do you anticipate that\nYES\nNO\nyou will be able to serve at some time in the future?\nIF UNABLE TO SERVE, GIVE MAJOR REASONS-\nhere\nDATE am employed the Veterans administration Hosfital and hoge to remain\n9\nSIGNATURE\naugust 17-1945\nVeta Blanche Markley\nYOUR FALUE AS A RED CROSS NURSE DEPENDS ON YOUR ABILITY AND WILLINGNESS TO SERVE AND YOUR PAITHPULNESS\nKEEPING US INFORMED OF YOUR ADDRESS. PLEASE FILL IN THIS QUESTIONNAIRE AND RETURN IT PROMPTLY TO the\nCOMMITTEE NAMED BELOW.\nATTENTION\nFill in committee name and address before sending questionnaire to nurseRecruitment\nCommittee\nSECRETARY\nPolk County Chapter ARC\nNURSE RECRUITMENT\nLes\n112 Flyon\nCOMMITTEE\nDes Moines, - Iowa\n78504M\nFORM 1045 Rev. July 1945"
}