One leaf typewritten and handwritten in pencil on the front side. The document is in good physical condition. The document was laminated. The lower right corner was folded into the laminate. There is a paper clip rust stain at the upper left corner. There is a paper clip-related tear at the upper left corner. There is a moderate tear at the upper left edge. There is a minor tear at the lower right edge. There is some significant staining of unknown origin on the lower half of the document. There is minor staining of unknown origin throughout the document. The document was folded both horizontally and vertically into eighths, possibly for mailing. There is a "3" handwritten in pencil at the upper left corner.