Box 1, Folder 22, Document 17

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Text Item Type Metadata


FORM 6-A-12 REV, 8/67

“Tf "Yes?! check with Interviewer

Have you ever applied CITY OF ATLANTA PERSONNEL BOARD Veteran

ROR et 260 CENTRAL AVENUE, S. W. Operator —
befere completing this form. ATLANTA, GEORGIA 30303 License #

‘ 12°95
522-4463, Ext. 267 Social Security Number: Pf 5


Cc QL ns haan 29 4969 Discharge ——______ Medical

License Education

Court Record ——___. Experience
Trade Report ——_______. Past Emp.
Additional Remarks:

e/ GEE KZ LETC aT Vili? ECE Line se ee
Ms Jit (TEALAD 5s LIL [ AL2 FOBT wal 2 BLE SS €.

Last at Firs st Middle | (or Maiden) “How long have you lived

Address AIEEE LYE LF bbb: [fofostosbipy “Go. SLY/ at this address?

Number Street Direction , Apt. No. City State Zip Code

previews adios 5/5 1). L/S 167) A Llib pate sp MELEE UE

7 fo x GY Y Exiats To
Telephone Number LEG 2b EY Place of Birth Lit. LUI CE é Lapa
Alternate Number Are you a citizen of the United States? fe, CLE al
Height Sele etl Dn What is your husband’s or wife’s name? 7 al
Check appropriate: White —____ Male Single f= Bivcced—— Widow —____—._ No. of children cS

Colored Female 2 Married Separated Widower ——__ No. of dependents Sn

If answer to any question below is ‘'Yes’’, explain. (Ask for_extra sheet if needed).


Have you any disease, physical disability, or defect? b

Have you ever been treated for a nervous or mental condition? SF.

Are you receiving disability compensation? ff ‘

Have you ever been sued on a debt? eels Have you ever had your wages garnisheed? ae

- Have you ever filed for or been awarded bankruptcy judgment? = 7p = Have you any past due debts? i ——


Have you ever been arrested or given a traffic ticket? LFS <_.
If **YES" list all crimes or misdemeanors, including traffic violations, with which you have been charged. Failure to admit any offense

regardless of when or where it occurred, may cause rejection of application. (Ask for extra sheet if necessary).



List any machines or equipment that you can operate efficiently. Are you presently employed?__f7 4)
Jf) — c Have you ever worked for the Ciry of Aisin an When

LLLEPAL. SL Ld CF 22 Are you interested in permanent work?_. ee nee
of ot, Are you willing to accept remporary worl i

Have you had military service? How many times were you in service? -

Were all discharges ‘‘Honorable’’?


Branch of Service Service Duties

Dace enlisted = Discharge reviewed by

Date separated . Reason for discharge

VA letter dared Per cence disabilicy _-__——EESSS——s« 3RReemarrksss

Serial or File No.

‘ Year Bncivclé ‘hich
Educational Record Name of School & Location Attended | Graduate pile complecat 3
Elementa YL Si ye =
ntary = Aone - GW LOM ay: a QWicB y V7 - 5G Ape 1+2-3-4-5-G-7-8
High School Vig Nee Sp | Yess 10-1142)
LLL 1) [lip-t2 = Dye & VFL No Cee

College, Univ. : ee id

No Degree & Major Subject
Post Graduate Yes

Trade or Yes
Business School No ede

“EMPLOYMENT RECORD: Account for all time since school,

Incomplete applications rejected. (Extra sheet may be obtained from interviewer).

Firm’s Name (7

Date Seared] WA, VG 7 Chloe

VLBA: LD Lee Loy fe

Final satary/ 5 OR

Mailing Address. 5B x 2 Ataf J 20 Li a

Date Left ; S
“Yih L&E A} si). BOS 65
Reason fot Leaving Number Street Direction / City State Zip Code
iy Despribe Duties
VEL, Ned 7 Le
/ Ota « GUC WZ. HO L270 Deter 2A! bez AD
—/. Dare Started ; hee “Firm's Name (OG L Ay AL Uce Cori er ete Ly
Lhe LTAY LG cag Le: Pe Lie Final Satry Uclenth ann
Date Left Mailing Address ae ee 95 %
ULE ah), [of tp Mt LOL LD Lil se, ands Pape
Reason for Leaving: Number “Street itection City State Zip Code
yn fret Bry, COR Ge 4) Describe Duties
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Date Started . poe ” Firm? ‘Name ' ; = if
te . i» ry ed eis u- fee. ce et fr Awe é ¢ Pear ied Final Salary (fast Lt
Date Lef . Mailing Addres A Co he
ate Left jy, g iling ress te fo ee PAM Ry ote Aa Ie. GS SS igots fx
2h Reason for Leaving Number Street ~»* Direction - ‘City State Zip Code
Na ag th Describe Duties | '
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Lp ¢ ss ep AT agen Ae reta a Le fs dé acl ¢ aes
/Date Started Je Firm’s Name : ae 4 | Scar J.
3 Sergi th \ iy ies 1 | JA Pee dd aap f° Op peote ¢_}' Final Salary (i ao
Date Left ey Mailing Address — A (" a / 5 rf Dy ot ges re
Cf (2X : / C SlCende St £2 Ath Ce fect
Reason for Leaving _ Number * Street . Direction ° City “State Zip Code
Describe Duties
Aj Pk) J Lyf oe
We 6 rok tt ee Af RL CEE Ca
Date’ Started | Firm’s Name vias ee f j
/- LAxCe Pee he 5 Final Salary
Date Left Mailing Address Lier 34 — ay!
Reason for eat ies Number Street Direction 4), “City” e j /Stace | Zip Code
4 D ibe Duties O&A ie
> 4 escrbe Dutt 3 / he
A t Oe , ik bee O49: . fhe re = Le ' fre #
AL f fRIG Dh Pts
a Pat = el ee
2A Zot oe List names and complete addresses of three character references. Do not list relatives or former employers.
IIT, ICE: Lz21% DE tt tnTe ; Des niece SC BLS
ff Numb “Street; Direction City State Zip Code
WoL Lisle ais L277 Lh eG Zl Me AlLMerh a Brey
— - -
tis iy SORES Number Street’ pve Direction LJ State Zip €ode
pote tere.
Yl“ Vie, 27 Crt’ C25) C+ LD “Sohn. LL lever, ATe. Jeo Brey
= Ea Number Street Direction City State Zip Code
I do solemnly swear (or affirm) that the statements in this application are PI i *
i complere - the best of/my a and belie i fF}
py (2) i hoFe Zz Reviewed by
lg Y Mile Pos
fs Rote

4 font all

FULL NAME: Opphy're LA fe } OA FSS LE i // Lp, i)

ADDRESS : fZ 20 (Apaty Spd Sy LD ves AFL ff Ad 2TA

Number Street _ Direction “(Apt. ae ive State Zip

EXAMINATION: hie af glee Ld) DATE a 2 & ae

I certify that I am the above individual taking this examination. I understand
that if it is later established that I have misrepresented myself, I and the
person being misrepresented will be permanently barred from City employment

and may be prosecuted by the courts. If either is already employed by the

City of Atlanta he may be subject to eg ae

Po Go sasgoe?
SIGNED: Crd ign

oe 77 ee

Chk (flint Chin \

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