004 PHONE: SEX: F 194 NBR: MANNER LAST ENTRY: CURRENT STATUS: ABC MEMBER: N PHOTO ATTACHED(Y/N): Y ELIGIBILITY: 274A.12( C )( 09 ) PROV CODE: MULTIPLE(Y/N): N NONE(Y/N): N (ENTER DATES AS MMDDCCYY) EMPLOYMENT START DATE: EXPIRATION DATE: NAME ON CARD: ISSUE CODE: CARD ISSUE/DENIAL DATE: OFFICER