Permanent Address: Bethpage, Tenn.

Age: 21

Date of Birth: Apr 6, 1896

U. S. Citizen: Natural Born

Where were you born: Bethpage, Tenn, U. Stat.

What is your present occupation: Laborer

By Whom Employed: Ed. A. Woodson

Where employed: Bethpage, Tenn

Have you a father, mother, wife, child under 12, or a sister or brother under 12, solely dependent upon you: No

Married or /Single: Single

Race: Caucasian

Signature: John Wesley Adcock
X
his mark

Registrar's Report
Tall, Medium or Short: Short
Build: Slender
Color of Eyes: Black
Color of Hair: Black

Remarks: Blank

Date of Registration: June 5, 1917