Name

Jessie Danahy

Social Security Number:

427-XX-XXXX

Date of Birth:

11/3/30

Date of Hire:

8/21/51

Previous Employer::

seasonal work with MS highway admin. road construction crew

Address:

19 South 10th Street, Rear, Oxford

154 North 15th Street, Apt. 1C, Oxford

King Road, Box 58, Oxford

Telephone:

none CEntral 4-1973

Telephone:

CEntral 4-5448

Notify in Case of Emergency:

(Name, Address, Telephone, Relationship)

Austin Danahy, Mt. Zion Church Road, Box 132, Oxford - Uncle

Luke Danahy, Mt. Zion Church Road, Box 81, Oxford - Father

Is employee a participant in voluntary payroll deduction life insurance plan?

Yes No X

Beneficiary Information: (Name, Relationship, Date of Birth)

Changes: (Date, description, if beneficiary change include relationship and date of birth)

Health Record/Company Physical:

8/22/51 passed company physical

8/24/54 passed company physical

8/19/57 passed company physical

Termination Information:

4/11/58 layoff