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QUINTUPLICATE
Form No. 200
Revised 5-15-18
AMERICAN RED CROSS
11s 21
SERVICE APPLICATION FORM
very to
5
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
Auga 3, 1918.
1. Name
in full Amgolion Ponão Didior
Telephone No.
69
2. Permanent Address Vie
(Number and Street)
(City)
(State)
3. Temporary Address, if any, to what date
Semo an nhovo
(Number and Street)
(City)
(State)
4. (a) If any changes of residence since August I, 1914, give these in full with dates
Tomo
(b) What is your present business or professioni
a
Name of firm or corporation with which associated Ibspital
Duration of Service
Flovon yoard
Present Capacity Suporintondont
Business Address Vale
(Number and Street)
(City)
(State)
5. Date of Birth 3005
Oote
36 (a) Place of birth Va.
(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
(a) Number of Dependents. Tono
(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
(g) Birthplace and nationality of father Delefrozo, 2M. -
(h) If father foreign born, whether naturalized, when and where
(i) Full maiden name of mother
Inthorino Nont
(j) Birthplace and nationality of mother
- Amorican
(k) If mother foreign born, whether naturalized, when and where
(I) Full name and nationality of paternal grandfather Houry Ae DidSot - American
(m) Full maiden name and nationality of paternal grandmother Angolico Zonlo -
(n) Full name and nationality of maternal grandfather Jomos Kont - Imorican
(o) Full maiden name and nationality of maternal grandmother Hianle Olivor - Amotrican
I
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
of
a
Vinchostor Ibopital from Jone 2007 until prosont time
a
Page data
- Page
- 13
- Source index
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- Type
- photo
- Media ID
- bd159fbe5c3f9c6f
- Size
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Document data
- ID
- 2661362
- Core
- doc
- Type
- document
DTO data
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Document source extras
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Page context
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"ocrText": "QUINTUPLICATE\nForm No. 200\nRevised 5-15-18\nAMERICAN RED CROSS\n11s 21\nSERVICE APPLICATION FORM\nvery to\n5\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\nAuga 3, 1918.\n1. Name\nin full Amgolion Ponão Didior\nTelephone No.\n69\n2. Permanent Address Vie\n(Number and Street)\n(City)\n(State)\n3. Temporary Address, if any, to what date\nSemo an nhovo\n(Number and Street)\n(City)\n(State)\n4. (a) If any changes of residence since August I, 1914, give these in full with dates\nTomo\n(b) What is your present business or professioni\na\nName of firm or corporation with which associated Ibspital\nDuration of Service\nFlovon yoard\nPresent Capacity Suporintondont\nBusiness Address Vale\n(Number and Street)\n(City)\n(State)\n5. Date of Birth 3005\nOote\n36 (a) Place of birth Va.\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\n(a) Number of Dependents. Tono\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\n(g) Birthplace and nationality of father Delefrozo, 2M. -\n(h) If father foreign born, whether naturalized, when and where\n(i) Full maiden name of mother\nInthorino Nont\n(j) Birthplace and nationality of mother\n- Amorican\n(k) If mother foreign born, whether naturalized, when and where\n(I) Full name and nationality of paternal grandfather Houry Ae DidSot - American\n(m) Full maiden name and nationality of paternal grandmother Angolico Zonlo -\n(n) Full name and nationality of maternal grandfather Jomos Kont - Imorican\n(o) Full maiden name and nationality of maternal grandmother Hianle Olivor - Amotrican\nI\n8. (a) What 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\nof\na\nVinchostor Ibopital from Jone 2007 until prosont time\na"
}