Part 88, page 78

Transcript

The scan is the source; the transcript is machine-generated from it.

SEE REVERSE SIDE FOR CORRECTIONS

ARIZONA CLASS: 4 SOCIAL SECURITY NUMBER: 327-26-[illegible]

[Handwritten annotation upper right]: M. [illegible] 0 [illegible]

FIRST NAME: ARTHUR MIDDLE NAME: B LAST NAME: DERHAM

EXPIR[ES] ON Y[EAR] BIRT[HDAY] [illegible]

STREET ADDRESS: 3405 S. TOMAHA [guess: LN]

CITY OR POST OFFICE: APACHE JUNCTION ZIP: 85220

SEX: M WEIGHT: 150 HEIGHT: 5'9" EYES: Bl HAIR: BR RESTRICTION: [blank] ORGAN DONOR: [illegible]

DATE OF BIRTH: MO: 02 DAY: 07 YEAR: 33 DATE OF ISSUE: 1-9-85 MED CODE: [blank]

× Arthur B. Derham (SIGNATURE OF APPLICANT) ASSISTANT DIRECTOR ADOT MOTOR VEHICLE DIVISION

[Bottom partially visible]: [illegible] FORMER NAME IF PREVIOUSLY [illegible]

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DB Cooper-38968