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1. What is your own age? Age of voucher, not applicant, is wanted. If you so prefer, the statement that you are over 21 years of age is sufficient.

2. What is your occupation?

3. What is your business address in full?

4. What is your actual bona fide (legal) residence? City and State?

5. How long have you been such resident thereof?

6. How long have you been acquainted with the applicant?

7. Is the applicant addicted to the use of intoxicating beverages, tobacco, morphine, or opium? If so, to which?

8. Has the applicant ever been addicted to the use of intoxicating beverages, tobacco, morphine, or opium? If so, to which?

9. Is the applicant a person of good moral character, and of good repute?

10. Are you related to the applicant? If so, what is the relationship?

11. Are you aware of any circumstances tending to disqualify the applicant for the public service?

12. Would you yourself trust the applicant with employment requiring undoubted honesty?

13. What is the name of the applicant for whom you furnish this certificate? First name, middle initial, or initials, if there be any, and last name, should be correctly given.