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4. Month and year of birth and age last birthday
Print

Month

_____

Year

_____

Age

_____


5. Month of birth

Fill one circle

[] January - March
[] April - June
[] July - September
[] October - December


6. Year of birth

Fill one circle for first three numbers

[] 186_
[] 187_
[] 188_
[] 189_
[] 190_
[] 191_
[] 192_
[] 193_
[] 194_
[] 195_
[] 196_
[] 197_

Fill one circle for last number

[] 0
[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
[] 9