Social Security Application


FORM 88-5 TREASURY DEPARTMENT INTERNAL REVENUE SERVICE	U. S. SOCIAL SECURITY ACT APPLICATION FOR ACCOUNT NUMBER	288-07-2724
PRINT NAME 1. Wilbert Omer Roads (EMPLOYEE'S FIRST NAME) (MIDDLE NAME) (LAST NAME)
2. RR #10 (STREET AND NUMBER)	3. Dayton Ohio (POST OFFICE) (STATE)
4. DAYTON MALLEABLE IRON CO. (BUSINESS NAME OF PRESENT EMPLOYER)	5. DAYTON OHIO (BUSINESS ADDRESS OF PRESENT EMPLOYER)
6. 41 (AGE AT LAST BIRTHDAY)	7. Sept. 26 1895 (DATE OF BIRTH)	8. Montgomery Co. Ohio (PLACE OF BIRTH)
9. Frank Valentine Roads (FATHER'S FULL NAME)	10. Ida Elizabeth Hull (MOTHER'S FULL MAIDEN NAME)
11. SEX: MALE X FEMALE -	12. COLOR: WHITE X NEGRO - OTHER -
13. IF REGISTERED WITH THE U. S. EMPLOYMENT SERVICE, GIVE NUMBER OF REGISTRATION CARD none
14. IF YOU HAVE PREVIOUSLY FILLED OUT A CARD LIKE THIS, STATE none (PLACE) (DATE)
15. Dec 4, 1936 (DATE SIGNED)	16. Wilbert Omer Roads (EMPLOYEE'S SIGNATURE, AS USUALLY WRITTEN)
DETACH ALONG THIS LINE

last modified: 98.07.13