. First Name 6. Last tam* t O. Date of Birth S. Address 10. City 11. State 12. MP/Postal Code 13. County 14. SEN NS Pereowitenil.S Pews) 16. Identification Wenner MN. Paaaptettamtee or odor "heir ciremeeco amber) 15E. tato of Issuance: 15b. Country of Issuance: 16. Ownership % umfen feu a a 0143•04 novate. Nc