Issued to Prisoner 5494 in Lwow Ghetto
Front: Tan form with printed information in a list on the lefthand side and information written in pencil in printed boxes on the righthand side. A blue oval stamp with Star of David on lefthand side, and a red checkmark in the middle.
Back: Printed infromation in a list on the lefthand side (bullet points 9-12) and information written in pencil in printed boxes in the righthand side. Includes a purple stamp with date in middle. These pre-printed forms were used for determining an individual's work in the Lwow Ghetto.