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दस्तावेज़
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OCR Page 1 of 35B
FORM NO. 1
u
TE RED
at
a
NURSING SERVICE
F
-
APPLICATION FOR ENROLLMENT
a
(To be filled out entirely in applicant's handwriting)
Name of in full Floruce C. Bullard
I.
applicant
2.
Address in full 12 marian Ave. glens Falls nawyork
3. Date of birth January 2th 1882.
Place of birth. Alesable Forks Nawyork
4.
Are you married, single or a widow? Singh
Are you a citizen of the United States?
no. yes
5. Have you any physical defects or tendency to constitutional or pulmonary trouble?
6. Name educational institutions attended before entering training school, stating number of years at each and from which you
were
graduated Ausable Forks High School.
Creatyteian Ill
7. Occupation
before entering training school
8. From what hospital training school did you receive your diploma? Give location of hospital and date of graduation
St. marys Hospital Fraining School. Mayo Broo.)
Rochartta minu. may- 1913
9. If your training as a nurse was received in more than one hospital, give name, location and time spent in each
IO. Character of hospitál: General?
P.G. in yas. Hospt Special? Newyork city Private? Eight months
II. 12. Daily average patients hospital yes. during training 20-d
Did your training include the care of men? Contagious diseases?
number of in
Length Obstetrics? of course yes. 3 3 years
13. Name and address of superintendent of training school under whom you received training
miss mary H. mayers. Long Island Hosph Bostre Harbor
14. Of what nursing organizations are you a member?
M. maryis alumn and manlattan and Brney. Newyork
15. Which, if any, is affiliated with the American Nurses Association? man-hattan Broup.
16. Give name and address of secretary of at least one of these organizations miss Schnidl.
Secty +Leasure it 4-mary's alumni
17.
Are you a registered nurse? yet In what state? Newyork Date of registration Oct.6. 1904
18.
State how, where and for what period of time, in each instance, you havé been employed since graduation, including present
Prinainder if time, coustant special duty
employment big it months at Prestyteaan Horph. nawy A.
At Two present, am completing swarth mouth in/Drrton general
fracturas.
19. Should our country be involved in war, would you be available for active service?
Uas.
20. Would you be willing to take the oath of allegiance?
yes.
21. What languages other than English do you speak?
Nona.
22. Name and permanent address of nearest relative. mr. thas. m. Bulland. Butter)
12 marian Ave. glaus Falls Newyork
Date June 5th 1916.
Signature. Floruce C. Bullard.
This blank is to be sent to applicant with circular letter Form 7, together with Form 11, and rules governing enrollment. After
approval
and endorsement by local Committee to be forwarded with "credentials" (Forms Nos. 3 and 4) together with Forms 10-11 to the
Chairman, National Committee on Red Cross Nursing Service, Washington, D. c.
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