Permanent Address: Hendersonville, R1, Tennessee

Age: 21

Date of Birth: December 28, 1895

U. S. Citizen: a Natural Born Citizen

Where were you born: 6 Dis., Sumner Co., Tenn

What is your present occupation: Farmer

By Whom Employed: Myself

Where employed: 6 Dis., Sumner Co., Tenn

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: T. H. Rice

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

Remarks: No

Date of Registration: June 5, 1917