EFTA00187083 # IRE CONTINENTAL INSURANCE COMPANY FIREMEY INSURANCE COMPANY OF NEWARK, N.J. COMMERCIAL INSURANCE COMPANY OF NEWARK, N.J. NIAGARA FIRE INSURANCE COMPANY THE FIDELITY AND CASUALTY COMPANY OF NEW YORK THE BUCKLEY UNION INSURANCE COMPANY THE GLENS FALLS INSURANCE COMPANY Branch Office Business name: Burey made to one of the above named Companies thereafter called "the Company" selected by the Employer. Mr. Elsa or Miss Elsa. Position: Trainer Bear Stearns & Co. Payable to: 55 Water St. New York, N.Y.10041 Employees: The Nature of the Employee's Business is: Stock Brokers Full Name of Applicant (Please Print) 26 Social Security Number 1-20-50 Date of Birth Are you an American citizen? Single? Married? Separated? Divorced? How long have you been in the continuous service of this employee? Do you receive any income beyond that of this employment? Do you receive goods, merchandise or other property on consignment or otherwise? Have you ever failed in business or compromised with creditors? No, if so, please state and source? Do you receive goods, merchandise or other property on consignment or otherwise? Have you ever failed in business or compromised with creditors? No, if so, please state and source? What were your banking connections at that time? Do you own your home or hold interest in another real estate? Location of such reality Description Value Have you any debts or liabilities other than for current expenses? No, please give amounts and state how they were incurred. If paid by salary, state annual amount and when payable. Have you ever applied to any company for a bond? If so, when? Have the company issued the bond? If so, when? What ground was the bond released? If so, please give particulars. **APPLICANT'S PARENTS IF LIVING, OR OTHER NEarest RELatives** | NAME | RELATIONSHIP | OCCUPATION | ADDRESS (Street and No. in city) | | :--- | :--- | :--- | :--- | --- *The continental insurance company* *Firemey insurance company of newark, n.j.* *commercial insurance company of newark, n.j.* *niagarra fire insurance company* *the fidelity and casualty company of new york* *the buckley union insurance company* *the glense falls insurance company* *branch office* *application is hereby made to one of the above named companies thereafter called "the Company"* selected by the Employer. *Mr. Elsa or Miss Elsa.* *position: trainer* *Bear Stearns & Co.* *55 water st. new york, n.y.10041* *The nature of the employee's business is: stock brokers* *full name of applicant (please print)* *age: 26* *social security number: 1-20-50* *date of birth: no answer* *are you an american citizen? yes* *single? married? separated? divorced?* *how long have you been in the continuous service of this employee?* *do you receive any income beyond that of this employment?* *do you receive goods, merchandise or other property on consignment or otherwise?* *have you ever failed in business or compromised with creditors?* *no, if so, please state and source?* *what were your banking connections at that time?* *do you own your home or hold interest in another real estate?* *location of such reality? description value* *In what position?* *trainer* *employed at New York* *died taking present position requiring this title* *76* *if so, please state and source* *have you ever given amounts and state how they were incurred?* *if paid by salary, state annual amount and when payable?* *have you ever applied to any company for a bond?* *if so, when?* *have the company issued the bond?* *if so, when?* *what ground was the bond released?* *if so, please give particulars.* EFTA00187084 Furnish below full particulars of your past occupations or employments during the last ten years, as called for under the column headings. If you were at school within this period, give accurate identification and attendance at each school. Begin in the top space with your most recent activity. If the spaces here are insufficient, please complete the record on a separate sheet and join together. PLEASE TYPE OR PRINT INFORMATION BELOW

From	To	Full name or exact style(if firm or corporation) of your employer and his business and address.	Town and street address of place where you worked.	Name and present address of your Superintendent.	Nature of your position or occupation.	Why did leave?
Month 91924	Month New1924	DALTH SCHOOLS108 Q45 SS	106 889S.N.Y.1		TEACHER	1413
Month	Month
19	19
Month	Month
19	19
Month	Month
19	19
Month	Month
19	19
Month	Month
19	19
Month	Month
19	19

Give as references the names and post-office addresses in full of three or four persons well acquainted with you during the past few years and not related to you. They should be persons of good standing in their respective communities. Please do not refer to any officer or fellow-employee in the service in which you are engaged, nor to any former employer.

NAME	PROFESSION OR BUSINESS	RESIDENCE ADDRESS IN FULL(Street No. and City)
Dr. T. Kafka	386/10 Vechta Ptec.
Jeffrey Niedi	Lawyer.
Fame Patterson	Person Director
K. Sutor	Educator

I hereby declare that the foregoing statements are true, and I hereby apply to the Company for a bond in my behalf of such kind and in such amount as the employer to be named as beneficiary in the said bond may now or hereafter require. I also hereby agree for myself, my heirs, executors, and administrators, to indemnify the Company against any losses, damages, costs, charges and expenses it may sustain, incur, or become liable for in consequence of my acts while under the said bond or any renewals thereof, or any new bond issued in continuation thereof or as a substitute therefor; and any proper evidence of the payment by the Company of any such losses, damages costs, charges, or expenses shall, in the absence of fraud on the part of the Company in making such payment, be conclusive evidence against me, my heirs, executors, and administrators, of the fact and extent of my liability to the Company under this agreement. I hereby further agree that the Company shall have the right to decline to grant the bond applied for; that, in case the bond is granted, the Company shall have the right to withdraw or cancel the bond at any time; that the Company shall not be required to disclose the reasons or grounds upon which any action on its part in connection with the said bond may be based; and that the Company shall not be responsible for any loss or damage that I may suffer by reason of any such action, any statutory provisions to the contrary being hereby expressly waived by me. This agreement may not be changed or modified orally. No change or modification shall be effective unless made by written endorsement hereon signed by an authorized representative of the Company.