Permanent Address: Mitchellville, Tenn

Age: 28

Date of Birth: Sept 29, 1889

U. S. Citizen: Natural Born

Where were you born: Mitchellville, Tenn.

What is your present occupation: Farming

By Whom Employed: Self

Where employed: Mitchellville, Tenn

Have you a father, mother, wife, child under 12, or a sister or brother under 12, solely dependent upon you: Mother

Married or /Single: Single

Race: Caucasian

Signature: William H. Worley

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

Remarks: Blank

Date of Registration: June 5, 1917