Application to go Abroad

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.

Originally posted on February 17th, 2013.

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