Permanent Address: Saundesrville, Sumner Co., Tenn

Age: 25

Date of Birth: July 19, 1891

U. S. Citizen: Natural Born Citizen

Where were you born: White House, Tenn

What is your present occupation: Farming

By Whom Employed: Own crops

Where employed: Saundersville, Tenn

Have you a father, mother, wife, child under 12, or a sister or brother under 12, solely dependent upon you: None

Married or /Single: Single

Race: Caucasian

Signature:
Jesse Clay Bloodworth

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

Remarks: Blank

Date of Registration: June 5, 1917