Name Mary Pearl Willis (Malieka)
Address 1435 Alvarado Terrace
Phone No phone
Mem # 1152
Mailing Add Same as Above
Soc Sec # 439-54-5540
Male ___ Female X Weight 170
Date born 12-21-40 Where born Rayville, Louisiana
Birth cert X Passport X Years school 12yrs.
Comm 25 c (irr) Health: HBP X Heart __ Diabetes ___ Vision X Arth ___ Other X
Married ___ Single X Divorced ___ Widowed ___ Own ___ Rent X
Spouse _____
Address _____
Phone _____
Mem # _____
Mailing Add _____
Soc Sec # _____
If not a member, how does he/she feel about your going? _____
Income SSA ___ SSI/SSP ____ AFDC ___ VA ___ State Dis ___ RR ___ Earnings X
Employer AAA Nurse Register Address Works in All Hospitals
Phone ___ Job LVN – Practical Nurse
I understand that if I am seriously overweight or have serious medical problems I will not be able to go on the short-term trips because of the hazard to my health and the additional strain my condition will create. I also understand that air travel is extremely expensive and that I will have to donate my fair share of the cost for transportation, food and lodging.
Signed Mary Willis
Date April 17, 1977
Wkr. R.F.