National Roster of Professional Women Questionnaire, 1971, page 1

          [handwritten] File 

NATIONAL ROSTER OF PROFESSIONAL WOMEN

Social Security Number 

1 . Name
Last - First - Middle or Maiden

2. Address
Number - Street
City - State - ZIP

3. In what year were you born?‘
Year

4. Are you: (Circle One)
White/Caucasian 1
Black/Negro/AfroAmerican 2
Oriental 3
American Indian 4
Mexican American 5
Puerto Rican American 6
Other 7

5. Where were you born? (Circle One)
USA 1
Canada 2
Central or South America 3
Western Europe 4
Eastern Europe 5
Africa 6
Far East 7
Middle East 8

6. Your religion (Circle one in each column)
Religion - Religion in which you were reared - Present religious preference 
Protestant 1
Roman Catholic 2 
Jewish 3
Quaker 4
None 5
Other (specify) 6