[306] Printed with duplicate on yellow paper beneath for carbon copy.
ORDER FORM—A[307]
| Date | ||||||||||
| ORIGINAL REPEAT | BUREAU OF SPECIAL RELIEF | ORIGINAL ORDER | ||||||||
| No. | Date | |||||||||
| Surname | ||||||||||
| First Name: | Man’s | Woman’s | ||||||||
| Address | ||||||||||
| Address April 18, 1906? | ||||||||||
| Number in family? | Ages | |||||||||
| Adult Males? | Ages | |||||||||
| Adult Females? | Ages | |||||||||
| Name | Occupation | Where Employed | Amount per Week | |||||
| Amt. Recd. from Rehab. Com. $ | Date | |||||||||||
| How expended? | ||||||||||||
| Insurance? | Companies? | |||||||||||
| Savings Amount? | Bank: | |||||||||||
| Real Estate: | Value: | |||||||||||
| Location: | ||||||||||||
| Other resources: | ||||||||||||
| Residence Continuous in S. F. since April 18th? | ||||||||||||
| Will require relief for: | ||||||||||||
| Reason for requiring relief: | ||||||||||||
| Physician attending? | Paid? | ||||||||
| Articles required: | |||||||||
| Meat Order | |||||||||
| Approved | |||||||||
Above form as [illustration]
[307] Printed with duplicates on yellow paper for carbon copies.