Part 86, page 72
Document date 13 December 1971
FBI 164-81, Vault Part 86 p. 72 (DB Cooper-37916), Form, dated 13 Dec 1971 — cooper.theunsolved.net/parts/Cooper-Part-86/pages/72
Transcript
The scan is the source; the transcript is machine-generated from it.
Northern Virginia Doctors Hospital Approval of Employment and Payroll Authorization
NAME Jack Coffelt First Middle Last
DEPARTMENT O.R. SHIFT 9-530
FORMS COMPLETED BY EMPLOYEE: State Tax Withholding Statement ✓ Federal Tax Withholding Statement ✓ Hospitalization: None ________ Individual IND Family ________
PHYSICAL REQUIREMENTS: (To be initialed by Departments) X-RAY [blank] LABORATORY [blank]
FORMS COMPLETED BY BUSINESS OFFICE: Payroll Record ✓ Leave Record ________ Switchboard Tab ✓ Pen. ✓
THIS FORM IS TO BE RETURNED TO THE BUSINESS OFFICE. NO SALARY CHECKS WILL BE ISSUED WITHOUT THIS FORM.
Car Tag # 1630
[signature: Jack Coffelt] Employee Signature
[redacted - Payroll Department]
F#104 Revised 2-24-69
[stamp: 14053]
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DB Cooper-37916
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b6 b7C