I don’t have this.
Here you can see a reproduction of the sheet taken from Jasper’s Rantings. he recreated it as a pdf so you can download and print it.
You can see some good photos of original copies here and here.
These character record sheets incorporate all the various elements that make up characters from all the Original D&D supplements.
From Greyhawk, we get things like the thief abilities and chance to open doors. There’s also the table for adjusting to hit scores against armour class depending on weapon type. From Eldritch Wizardry there’s psionics – sigh.
And I like Tom Wham’s whimsical art.
Date Information
As Zenopus states, the copyright information shows a publication date of April 25th 1977. Enworld also has this date. No particular reason to doubt this.