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Have you e ver applied for City of Atla nt a~ Q e mp\cyrr,~nc? ·' 1("Yes" -chec:k wi th Interviewer b efcre completing chi s form. 5i2-4463, Exe. 267 CITY OF ATLANTA PERSONNEL BOARD Veteran - - - -- - - - - - APPLICATION FOR CIVIL SERVICE EXAMINATION Chauffeur - - - - - - - - - 260 CENTRAL A VENUE, S. W. ATL ANTA, GEORGIA 30303 L icense# - - - - - - - -- Operato r - - - - -- - - -,-,J ,,? --7c;, / / . z:_L ( /)-re/ / 1/(,; ,

Socia l Security Number: , / / POSITION APPLIED FOR DATE DO NOT USE THIS SPACE DATE OF EXAM .Ir,·, t t-Oi (' _. ~ L ~CND 1Jf1N 9 ~ 1QRQ Discharge ' Medical License I I Experience Trade Report Pase Emp. Additional Remarks: ! ,4-1 _ I Mr. Education Court Record ,/ -- . rl - z. LO ~ . 6 2 -::.t_e,,·. C,:::-~fT //4V a ~ 17 "°. Alternate Number Heighc / 4/~I/ // Check appropriate: / /".. Weight White / - ,O{) o/ v").'ZJ=/.c(/Z.---::::, Telephone Number,· Place of Birch / fl <..--?-

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/ A e ·From ·-/2;- - - To C ;z -f.!!«7=:; Are yo u a c iti ze n of the United Scaces ?/c..,,.~v_/c.., -;_;--...,

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·(- - - - -- - - - - - - - Wha·c is your husband's or wi fe's n ame? _ _ _:,.1_ _ _ __ _ _ __ _ _ _ _ _ _ _ __ ~ ~7 z=:;>1ale - - - S in gle ~ i v orced---Widow 0 No. of children Colored - - - Female ~ 1 a rri ed - - - Separated - - - Widower - - - No. of depende nts _,___ _ _ _ _ _ _ __ If answer ro any ques tion be low is " Yes", explain. (Ask for extra sheet if nee d ed). Have you any disease, physical disability, or defect? f} /} Ha ve you ever been treated for a nervous or mental condition? Are you receiving disability compensation? Have you ever be en sued on a debt? fJ O 1J O ,0 I? . - Have .yo u ever h ad y~ur wa.ges garnisheed? ,rf (9 Have you ever filed for or been awarded bankruptcy judgmen t? EXPLANATI ON : - - - - - - - - - - - - - -- - -- -- Have you ever been arrested or given a traffic ticket? f 12 Have you a ny p as t due debts? ~/J--'/J-'-___ - - - - - - - - -- - -- - - - - -- -- - - - - - - - - - /J() If "YES" li st all crimes or misd e meanor s, includin g traffic violation s, w ich which you have bee n c h arged. Fail ure to admit any offe ns e regardless of wh e n or where it o ccurred , may cause rejection of applica tion. (A sk for extra sheet if n ecessa ry). _CHARGE List any mac hin es or equipme nt chat you c a n operate e ffici e ntl y. .W2v Ha ve yo u h ad milit ary service? ,.. "'.... w a: N <( J,

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a: 0 11. Are yo u pres e ntl y employe d? _ __,f?..,._..c/,.-,.... 7 ____~ /? f-;; Have you ever worked for the Ci:;o~ Atl a nt a ? - ~fl~.L~. 7_ ___ How many times we re you in se rvi ce ? _ _ _ _ _ __ _ / DO NOT WR IT E BELOW THIS LINE ' Branch of Se rvice Se rv ice Duties Da te en liste d Disch a rge rev ie wed by Dace sepa rate d Reason for dis c h arge Form Ho no ra bl ,. VA l e t te r date d Seria l o r File No . Wh e n _ __ _ Are y ou interes te d in p erma ne nt work?_,..,.-:/ .,.,/J .., .,5%? ~/.' ,,_,_______ .,. 7J/ V '1/,I Are you w illin g to accept te mp orar}' work?' b{fL<' Were a'll di sc h arges "Honorable"? - - - - - - - - - - -- - (IJ > SENTENCE i FINE CITY & STA TE WHEN P e r cent di sa bilit y Re ma rks �Educational Record Name of School & Location .t i ~ /4~"/7,Z- /'4/1/21/,,I(? / V;J/JJ./J·- v;?/4<1,,; v7 :&;· //·-;/ 7 . - ,efJ;; r . / /fl 'i~//4//1'-7 II /Yl/Y) - -·f l/.1/ /{ V ,.,.. _ / "' ....... El.cmencary - Hi gh School Lase Year Atte nd e d -· ly-5q ·vq._,i~· , -- c,..,v(/";,..,,'-',_..1-..,., College1 Univ. ' Post Graduate Encircle highest grade comple_tf. d. . / " ) ., Graduate 1-2-3-4-t§,-7·8 /~·!!.& Ye s ~ - 9-10-1 (i'y No Yes-- ·· N o - -- ~ Degree & Major Subj ect Yes-No - - Yes-NO - - - Trade or Business School . No. of months attended Final Salary;,·· 1) j, I I City Zip Code /,: .."-/ L.1! ~. ,,U ,f:-,_

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(,, l I State Dare Sta rted I . Dace Left ,f ( ,' \..__,./ Fina l Sa lary _· r .,·., .: , , (.~ Mailing Addre~s ~ / - 'v' .l Number Describe Duties cf _( ·j Street . State City / i ,.{', . / / ~ ·/;,,.,.!_, ' !'.:..- '. Mailing Address Rea s on ·for Le a ving Numbe r Des cribe Duti es , Zip Code Fina l Sala ry Street ') ,. . Dire'ction City '-- State Zip Code /, . Fina l Salary Number De scribe Duties , R eason for Lea vin g i, , <1 C\-•:'-/. ('..t •'./) - I/ j (.,, .) Mailing Addres~ c -/ I ,,, / t.c--.:.1'(_,,,.,-- { · '/ Dace L e ft < /, .') Firm's Na me I - /! - /, _A1i/.'t'. ;;!.. Da ce· Sea. reed .7 - / ·- ... Direction L ·) i '-/ . Firm's Na me ,.. Date Left ·- /i ~- ( i I ! / Dace Sta rt~ Zip Code 1-;:..., L Stree t Dire ctio n ~ / ).,_ 'J..'.-~ !. ._:.,.,:_;__,/ • \... REF E R E N.t ES: Li s t names ~nd comp l ete addresses of three c h arac te r ~e feren ces. Do no t li s t re l atives or former emp l oyers. . ADDRESS - ')' <!-,·'.,.(.~_ 4, "' ,·--(' ~// 65 c~ c.o.. Numbe r cruet S tree t I do solemnly swear (or affirm) chat the statements in this applicatio n are co~plete to/he best j 'my knowl edge,-~ nd b e ~ i e ~ /Cli,;!-,4,U? c/fJ}t lt¼£~.4,J?' ~ ' .,., · S~~of"Appli ca nc ,• J' . . , ... ': / j Directio n Zip Cocle C ity '° -J7 i._. I / Revie.w ed by / �•· . • ' r •' ·--- ·- -- -- - .I EXAMINATION: PLEASE PRINT FULL NAME: 3 (., L- 2 .,..9- ? 79- ,-12 .,a(tjj;.....- - - - - - - DATE +.,'(/_id'-'""_~~,/~~ . -=--.-.~-----~, . >s.,. / 'r,.- .- - ,. . , e r I - l1. L L 1.;-f!f / r--2 (MIDDLE NAME • Le~ (FIR~'i' NAME) IF NONE PUT NMN) I certify that I am the above individual taking this examination. I understand that if it is later established tha t I have misrepresented myself, I and the person being misrepresented will be permanently barred fro m City employment and may be ptosecuted by the courts. If either is already employed by the City of Atlanta h.e may be subj ect: to suspens ion dismissal. 1/ L_ . ? /~ ,.:j /J ,. I ·"/./ . . . . . \.., S IGNED c,-. . "")v:~;;.1 ,1..-.L-"J, ·1",-~-- _;,.. -~~ ._; ,J ~ -. /;7 (,_/ _.J ~d ,1/' ~ _."'t"

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