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| Front | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Name | Age | Address | Birth date | Citizen? | Place of Birth | Nat. | Occ. | Empl. | Loc. | Closest relative | Mar./Race | Mil. | Dep. | Exempt | (Signed) |
| Max Chervin | 21 | 183 Powell St. Bklyn NY | March 15, 1896 | Non citizen | Statchin, Lomza, Russia | Citizen of Russia | Operater | Bernstein | 1596 East NY Ave | Parents mother sick | Single White | None | None | Weak Heart | Max Chervin |
| Height | Body | Eyes | Hair | Crippled | Official Signed, Dated, Location | ||||||||||
| Grey | Black | No | Benj. Pollock, June 5, 1917, B'klyn | ||||||||||||
