32 



Regulations, I agree to submit to an examination by a physi- 

 cian, either selected or approved by the said Pension Board; 

 and I further make this statement of my age, term of employ- 

 ment, 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 



