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COLONIAL AIRLINES, INC. 

Please complete in full.        DATE__________
Print or type.
Return to: Personnel Dept.
           230 Park Avenue
           New York, N.Y. 

Name ______________________ Social Security 
       First Middle Last     Number _________

Date of Birth ________________________________
                   Month   day   year 

Present Address _____________________________
              Street and Number  City  State

Telephone Number _______________

Permanent Address ____________________________
                 Street and Number City State

Telephone Number ________________

Notify in Case of Accident ___________________
                            Name       Address
                   Telephone Number __________

PHYSICAL 
Sex ____  Single___ Married___ Divorced___
Height____ 
Weight____  Widowed___ Separated___ Engaged___
Color hair_______
Color eyes _____      Dependents
Hearing ____           Wife _______
Wear glasses _____     Husband ____
                       Boys (No. and age)_____
                       Girls (No. and age)____
                       Father _______
                       Mother _______

Nature of any physical defects ______________________________________________

Time lost due to illness during last six (6) months _______________________

Have you taken a recent physical examination ________ Results __________

Purpose ________________________