I agree to submit to an examination by a physician, either selected 

 or approved by the said Pension Board ; and I further make this 

 statement of my age, term of employment, wages, etc. 



Date of Birth : Year. , Month , Day , 



Place of Birth 



Regularly employed and on payrolls 

 of American Museum of Natural 

 History since 



Position 



Present Salary 



Name of Applicant 



Residence 



Date 



Witness 



