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.