Permanent Address: Saundersville, Sumner Co., Tenn

Age: 23

Date of Birth: April 1, 1894

U. S. Citizen: Natural Born Citizen

Where were you born: Goodlettsville, Tenn

What is your present occupation: Farmer

By Whom Employed: Farming for Self

Where employed: blank

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: Samuel D. Bloodworth

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

Remarks: Blank

Date of Registration: June 5, 1917