Permanent Address: Hendersonville, Tenn

Age: 24

Date of Birth: August 13, 1893

U. S. Citizen: Natural Born

Where were you born: Hendersonville, Tenn

What is your present occupation: Clerk in General Store

By Whom Employed: Sam Bloodworth & C

Where employed: Hendersonville, Tenn

Have you a father, mother, wife, child under 12, or a sister or brother under 12, solely dependent upon you: Father and sister

Married or /Single: Single

Race: Caucasian

Signature: J W Bloodworth

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

Remarks: Blank

Date of Registration: June 5, 1917