t Collection Page 2 of 3 Name of Applicant an Fan 8 / Date of Birth &um04310Y/ NI 1 Xi 11 I I I Ali ls: \ I \ I \fll [ I I II 12. Height 13. Heir Color 14. Eye Color 15. Occupabon 16. Employer 'I -I M \ [ It ie. \ 1 14 la At \ It% ,, \ I „4r .‘ „ \ - 1 17. Addltional • +gad ho 4 Nu to . l

Name of Applicant (Lass, First & &fridlo) EPSTEIN, JEFFREY EDWARD 12. Height 13. Heir Color stt . tira. GRAY 17. Additional Contact Phone Numbers 14. Eye Color BLUE 15. Occupation BANKER Hone Coll Wcrk Date of Birth (rnmidcVyyyy)