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...... | MOYER Je ic Ges te ») Day... .oae 
Plage of Birth. cavers ee cnk tee ole es ee eee 
Regularly employed and on payrolls 
of American Museum of Natural o SA ac eee see 
History since 
Position. . £. s/ods swe) dea eee ee ee ee 
Present Salary. so 6 ced) s dips a sine bea we ee ee se 
Name-of Applicatitis i560 26 62st das aoe: Dns ae ee 
Rasidente. ob ocd ethos eed dees Pa Se a ee 
