[1]14-00000
[3]104-10129-10002 | 2025 RELEASE UNDER THE PRESIDENT JOHN F. KENNEDY ASSASSINATION RECORDS ACT OF 1992] .
[5]rs
[7]“e etme,
[8]a ee eee “
[9]c - . =. if ~
[12]OO NOT USE THIS SPACE
[15]THIS DATE (Fill In)
[19]PERSONAL HISTORY STATEMENT
[21]AUGUST 31, /F6/
[23]- Answer all questions completely or check appropriate box. If question is not applicable, write “NA”. Write “Un-
[24]known” only if you do not know the answer and it cannot be obtained from personal records. Use blank Space at
[25]end of form for extra details on any. question for which you have insufficient space.
[27]2. Type, print or write carefully; illegible or incomplete forms will not receive consideration.
[29]3. Consider your answers carefully. Your signature at the end of this form will certify to their correctness. Careful
[30]completion of all applicable questions will permit review of your qualifications to the best advantage.
[32]SECTION | GENERAL PERSONAL AND PHYSICAL DATA
[33][EES BAME Cast Firat Micate) 1 [SEX
[35]YODRIGUEZ , EMILIa Amercce; 35 yenes Paueyrud hme pee
[36]. 6. COLOR OF EYES 7. COLOR OF HAIR 8. TYPE COMPLEXION 9. TYPE BUILD
[37]tow! SO ths. ROWN | BLACK “AuUDD MEDIUM
[38]10. SCARS (Type end Location) .
[39]NONE
[40]11. OTHER DISTINGUSHING PHYSICAL FEATURES
[41]NONE
[43]12. CURRENT ADDRESS (No., Street, City, Zone, State and Country)
[45]13, PERMANENT ADDRESS (No., Street, City, Zone, State and
[47]F36/ S.W.°179 ST. 930) SwenppsT, COME:
[48]., . ! : ‘ (CE dar S-8341
[49]“PERRIVE S7, FLA. PERRINE $7, FLA. ;
[51]A
[53]14. CURRENT PHONE NO. 15. OF FICE PHONE NO. & EXT. 16. LEGAL RESIDENCE (State, Territory or Country)
[54]f i 5
[55]Cdn S-§ 34s; NA. FLORIDA, U.S. 8.
[56]17. NICKNAMES 18. OTHER NAMES YOU HAVE USED
[57]NONE
[59][4UGENIc  GoNnzALEZ,!
[61]19. INDICATE CIRCUMSTANCES (Including Length of Time) UNDER WHICH YOU HAVE EVER USED THESE NAMES.
[63]Fike BPRIL 1760 To PRESENT (¥ ARVANA ,CHBA AND MIAMI FLG. as UNDERCOVER NAME
[65]20. 1F LEGAL CHANGE, GIVE PARTICULARS (Where and by What Authority). .
[67][SECTION tl POSITION DATA
[68]1. INDICATE THE TYPE OF WORK OR POSITION FOR WHICH YOU ARE APPLYING
[70](CONTRACT AGENT |
[74](You will not be considered for any position with a lower 3 DATE AVAILABLE FOR EMPLOYMENT x
[75]entrance aalary), 9,600.06 ‘COM TRRET ALREADY SIGWED,;
[77]. 4. INDICATE YOUR WILLINGNESS TO TRAVEL
[78]7
[80]5. INDICATE YOUR WILLINGNESS TO ACCEPT ASSIGNMENT IN THE FOLLOWING LOCATIONS (Check (X) each item applicable)
[82]|] WASHINGTON, D.C. bd ANYWHERE IN U.S. x CERTAIN LOCATIONS ONL Y (Specify):
[84]2. INDICATE THE LOWEST ANNUAL ENTRANCE SALARY YOU WILL
[85]ACCEPT
[87]OUTSIDE CONTINENTAL U.S.
[88]6. INDICATE WHAT RESERVATIONS YOU WOLD PLACE ON ASSIGNMENTS OUTSIDE THE WASHINGTON, D.C. AREA.
[90]ADEQUATE PAY AVD LIVING CONDITIONS OR
[91]S&LF AND FAMILY
[93]Fors 444 use Previous EDITION.
[96]14-0000
[98]SECTION In < ° CITIZENSHIP
[101]<n
[102]1. DATE OF AIRTH 2. PLACE OF BIRTH (City, State, Country)
[104]3. PRESENT CITIZENSHIP (Country)
[105]Say. 27/928) HAVANA. CuBR
[107]4. CITIZENSHIP ACQUIRED BY fs. DATE NATURAL- | 6. NATURALIZATION CERTIFICATE NO.
[108]| femme | [wanmace [XJotner (Speci yprueg.| Decentg er 1S} 1944 HEMIFATS }
[110]7, COURT ISSUING NATURALIZATION CERTIFICATE 8. ISSUED AT (City, State, Country)
[111]-S.Disrarcr Count of Ensrern Dist. of Lousstaw New Boe EAN S LA .-
[113]8. HAVE YOU HELD PREVIOUS NATIONALITY 4" IF YES, GIVE NAME OF COUNTRY
[115][Xives_ | ne Cu GA
[117]11, GIVE PARTICULARS CONCERNING PREVIOUS NATIONALITY.
[119]CUBAN BY BIRT Hf
[121]\. ARS
[122]12. HAVE YOU TAKEN STEPS TO CHANGE yes | 13. GIVE PARTICUL
[124]PRESENT CITIZENSHIP
[125]X[ No W.A.
[126]14. IF YOU HAVE APPLIED FOR U.S. CITIZENSHIP, WHAT 1S PRESENT STATUS OF YOUR APPLICATION (Firat Papers, Etc.)?
[128]N. A.
[130]15. DATE OF ARRIVAL IN U.S. 16. PORT OF ENTRY 17. ON PASSPORT OF WHAT COUNTRY
[131]UNE SC , [FE MIAMI, FLA. SWISS PROTECTIVE Passport
[132]16. LAST U.S. VISA (No., Type, Place of Iseue) 19. DATE VISA ISSUED
[133]RESIDENT _ ¥.5. EMBASSY IN HAVANA, CUBR Nov. /F4¢Z
[134]SECTION IV EDUCATION
[135]1. CHECK (X) HIGHEST LEVEL OF EDUCATION ATTAINED
[137]|| LESS THAN HIGH SCHOOL GRADUATE OVER TWO YEARS OF COLLEGE - NO DEGREE
[138]|| HIGH SCHOOL GRADUATE BACHELOR'S REGREE
[140]|| TRADE, BUSINESS, OR COMMERCIAL SCHOOL GRADUATE GRAOUATE STUDY LEADING TO HIGHER DEGREE
[141]a 7
[142]|| TWO YEARS COLLEGE OR LESS . Ds MASTER'S OEGREE |_| DOCTOR'S DEGREE
[144]2. ELEMENTARY SCHOOL
[146]1. NAME OF ELEMENTARY SCHOOL 2. ADDRESS (City, State, Country)
[147]COLEGIo DE LA SALLE! HAVANA , CUBA
[148]3. DATES AT TENDED (From-and-To) 4. GRADUATE
[150]Se . S93 76 Nov. FEZ : x] ves Two
[152]1. NAME OF HIGH SCHOOL 2. ADDRESS (City, State, Cowmtry)
[154]Néw @O¢lEANS , kR
[156]3. DATES ATTENDED (From-and-To) 4. GRADUATE
[158]Noy. (i420 Juve (245 (Xe SCS
[160]1. NAME OF HIGH SCHOOL 2. ADORESS (City, State, Country)’
[162]4. COLLEGE OR UNIVERSITY STUDY :
[163]REC’ HOURS
[165]NAME AND LOCATION OF COLLEGE OR UNIVERSITY
[167]) 4... SECTIONIV CONTINUED TO PAGE 3 ed
[169]14-0000
[171]@ | SECTION V FOREIGN LANGUAGE ABILITIES e
[173]-
[175], “*" SECTION IV CONTINUED FROM PAGE 2
[177]5. {F A GRADUATE DEGREE HAS BEEN NOTED IN ITEM 4 WHICH REQUIRED SUBMISSION OF A WRI
[178]OF THE THESIS AND BRIEFLY DESCRIBE ITS CONTENT UO REQUIRED SUBMIS TTEN THESIS, INDICATE THE TITLE
[181]Ft EPITETO EW LAS OBRAS DE BERCES (De wor REmemace Quer rerz é). A DETAILED:
[183]STUDY OF THE MANY USES OF THE EeirHer iy BERCEO'S WORKS A (2TH cevrury weiter:
[184]MELDING A CROSS - REFER ENCE SISTING OF Aik EPITHETS AS StlowNn IN HIS WRITINGS 7?
[186]6. TRADE, COMMERCIAL AND SPECIALIZED SCHOOLS
[188]a
[189]Wf a
[191]7. MILITARY TRAINING (FULL TIME DUTY IN SPECIALIZED SCHOOLS SUCH AS ORDNANCE, INTELLIGENCE, COMMUNICATIONS, ETC.)
[193]8. OTHER EDUCATIONAL TRAINING NOT INDICATED ABOVE.
[195]which you possess any degree EQUIV- FLUENT
[197]. COMPETENCE - IN ORDER LISTED
[198](Liat below each language in
[199]oe “ed
[201]ALENT ADEQUATE | ADEQUATE]: Limit an an -
[202]of competence. Indicate your To OBVIOUSLY FOR FOR Know. | Native |, PRO-
[203]proficiency to Read, Write or NATIVE FOREIGN | RESEARCH] TRAVEL LEDGE ° LONGED
[204]Speak by placing a check (X) FLUENCY COUNTRY IGeRCE
[206]in the appropriate box(es).
[208]plete fete tots te Tw Ts [a Tw Ts |
[210]0 ee
[212]tik XT XT ETE TTP
[214]alii titi tT Xx TT 2S
[216]Zriey | 11} TIT IT ELT XXX | BS
[218]2. IF YOU HAVE CHECKED “*ACADEMIC STUDY’ UNDER *HOW ACQUIRED”, INDICATE LENGTH ANO INTENSIVENESS OF STUDY.
[219]FRom (94% Yo 19S STUDIED THE RemtancE LANGUAGES AT THE GRADURTE
[221]LEVEL
[223]3. IF YOU HAVE INDICATED FLUENCY FOR A LANGUAGE HAVING SIGNIFICANT DIFFERENCES IN SPOKEN AND WRITTEN FORM,
[224]PLAIN YOUR COMPETENCE THEREIN.
[225]MN: 4.
[227]4. DESCRIBE YOUR ABILITY TO DO SPECIALIZED LANGUAGE WORK INVOLVING VOCABULARIES AND TERMINOLOGY IN THE SCIEN-
[228]TIFIC, ENGINEERING, TELECOMMUNICATIONS, MILITARY, AND OTHER SPECIALIZED FIELOS.
[230]FAMILIAR wiTtg SCIENTIFIC Awd ENGINEERING “TERMINOLO G Y W SPANISH.
[234]5. IF YOU HAVE NOTED A PROFICIENCY IN LANGUAGE, WOULD YOU BE WILLING TO USE THIS ABILITY IN ANY POS!TION FOR WHICH
[235]YOU MIGHT BE SELECTED? .
[236][Sd YES (_] No
[238]14-0000
[240]ne
[244]‘SECTION Vi a GEOGRAPHIC AREA KNOWLEDGE AND FOREIGN TRAVEL
[247]he List BELOW ANY FOREIGN REGIONS OR COUNTRIES IN WHICH YOU HAVE TRAVELLED OR GAINED KNOWLEDGE AS A RESULT OF
[248]* RESIDENCE, STUDY UR WORK ASSIGNMENT. INDICATE TYPE OF KNOWLEDGE SUCH AS TERRAIN, HARBORS, UTILITIES, RAIL-
[250]KNOWLEDGE ACQUIRED BY
[252]ORK
[253]TRAVEL /STUDY | ASSIGN-
[255]ROADS, INDUSTRIES, POLITICAL PARTIES, ETC.
[256]se
[258]DATES OF
[259]NAME OF TYPE OF ; DATES AND
[260]REGION OR COUNTRY SPECIALIZED KNOWLEDGE RESIDENCE PLACE OF STUDY
[262]w
[263]MENT
[265]Econ ‘ Weeine hactag Lipsy 19, |
[266]Comomic. ¢ SOCIAL uCTUK
[267]B A CMPLER E~ i Pee TarteWn ISS VIEL M.A. a™
[269]IM
[271]X
[273]LE
[274]_
[275]x
[277]“To worle As Assis lay t Disheick Mawgyen foa Coukna CLeclere Co. m chae <2
[278]of then Havawn Office, av Havant Cagy, Late Rembived iw Cuba pacer Mach Geo
[279]°f & Cffice, mm Havawa Cuba. Se ihe Caracal L ZH.
[280]3. UNITED STATES PASSPORT NUMBER AND EXPIRATION DATE, IF ISSUED. . a "
[281]s WEMOGS GE Expinet> Seph 2 (F€0 (wer genewed)
[282]SECTION VII TYPING AND STENOGRAPHIC SKILLS
[283]"TYPING (pay | 2. SHORTHAND (wpm)
[284]SO NA. | [erece | [sreeownitine | [stenorves | [otwen (Speci:  —*d
[285]2. INDICATE OTHER BUSINESS MACHINES WITH WHICH YOU HAVE HAD OPERATING EXPERIENCE GR—ERAINING (Comptometer,
[287]Mimeograph, Card Punch, Etc.). -
[288]MIMEOCGRAPH , ADDING MACHINE, CALCUL ATOR , DICTATING MACHINE .
[290]SECTION VIII SPECIAL QUALIFICATIONS
[292].1. LIST ALL HOBBIES AND SPORTS IN WHICH YOU ARE ACTIVE OR HAVE ACTIVELY PARTICIPATED. INDICATE YOUR PROFICIENCY
[293]IN EAC
[295]ACH.
[296]FIS, PP ; : ;
[297]MING, HUNTING, SWIMMING (Good UNDERWATER RESISTANCE ) PloTOGRA PHY
[298](BLAck # wHiTE AND Cocoe) | Musical p ; /
[300]Bow Iiy
[302]Wa Chess.
[304]Avega C (MY ALL OF THe Rgove .
[305]1,
[307]“Ay SEVEROL INSTRUMENTS GY EAR), FLYING
[308]7
[310]2. INDICATE ANY SPECIAL QUALIFICATIONS RESULTING FROM EXPERIENCE OR TRAINING WHICH MIGHT FIT YOU FOR A
[311]PARTICULAR POSITION OR TYPE OF WORK.
[313]Tegcuine Aap ROMS TRATIVE FRPERIENCE SECURED AT THE UnivERS: Ty
[315]LECEL AWD IN FOREIGN TRADE UANAGEMENT PESPECTIVELY. Akso
[317]CRPACITY Te CARRY eur WOE PENDENT PESERR CH AT THE GeRapurgre LEVEL.
[319]3. EXCLUDING BUSINESS EQUIPMENT OR MACHINES WHICH YOU MAY HAVE LISTED IN ITEM 2, SECTION VII, LIST ANY SPECIAL
[320]SKILLS YOU POSSESS RELATING TO OTHER EQUIPMENT AND MACHINES SUCH AS OPERATION OF SHORTWAVE RADIO (Indi-
[321]cate CW apeed, sending end receiving), OF FSET PRESS, TURRET LATHE, SCIENTIFIC AND PROFESSIONAL DEVICES.
[323]FAMILIAR WITH GENERAL SClEVTigve APPARATUS AS MAY BE PRESENT
[325]echeph fe wne Tay .
[327]/W A MEAL ReSERCCH “ABeRATORY Beckman
[329](Div ove VEOR RESEARCH AT TULANE MEDICAL Stu20L))
[331]SECTION VIII CONTINUED TO PAGE 5
[333]" . ( (
[336]14-0000
[338]» SECTION VIII CONTINUED FROM PAGE 4
[340]. ARE YOU NOW OR HAVE YOU EVER BEEN A LICENSED OR CERTIFIED MEMBER OF ANY TRADE OR PROFESSION, SUCH AS PILOT,
[342]ELECTRICIAN, RADIO OPERATOR, TEACHER, LAWYER, CPA, MEDICAL TECHNICIAN, ETC.?
[344]Bres [No
[346]. IF YOU HAVE ANSWERED “YES* TO ABOVE, INDICATE KIND OF LICENSE AND STATE_ISSUING LICENSE (Provide License Registry
[348]Number, if known).
[350]Student Blot Ceatifieate Wt S- 293957
[352]» FIRST LICENSE OR CERTIFICATE (Year of Isaus) 7. LATEST LICENSE OR CERTIFICATE (Year of Issue)
[354]4-18-S¢ MA-
[356]. LIST ANY SIGNIFICANT PUBLISHED MATERIALS OF WHICH YOU ARE THE AUTHOR (Do NOT ‘submit copies unless requested). INDICATE
[358]THE yr UELICATION DATE, AND TYPE OF WRITING (Non-Fiction or Scientific articlea, General Interest aubjecta, Novels, Short .
[359]tories, Etc.), .
[361]N.A.
[363]» INDICATE ANY DEVICES WHICH YOU HAVE INVENTED AND STATE WHETHER OR NOT THEY ARE PATENTED.
[365]WA.
[366]. LIST PUBLIC SPEAKING AND PUBLIC RELATIONS EXPERIENCE.
[368]IN COLLEGE AND AS 4 TumwR ExEcuTwE W FOREIGN TRADE
[370]. LIST ANY PROFESSIONAL, ACADEMIC OR HONORARY ASSOCIATIONS OR SOCIETIES IN WHICH YOU ARE NOW OR WERE FORMERLY
[371]A MEMBER. LIST ACADEMIC HONORS YOU HAVE RECEIVED.
[373]Phi he Lola , Nahowal Hower Seciely of Ronanee Hawgnases.
[375]Aweqrcay Associatin of Teachers of wish oud Bak ; e.
[376]Crenduate Sche Bas Mis of fered 4 7 the s of howt sane sad! Tabane Unweesi ly. :
[378]Cumd€R wey Z Dr five YEqas OF GRAD~ATE wogc) ! 7
[379]Howonney MEV Tions AWD MEDALS, .
[381]NOTE: (LIST LAST POSITION FIRST.) Indicate chronological history of employment for past 15 years. Account for all periods
[382]including casual employment and all periods of unemployment. Giveaddress and state what you did during periodsot
[383]unemployment. List all civilian employment by a foreign Government, regardless of dates. Incompleting item 9, “De-
[384]scription of Duties” consider your experience carefully and provide meaningful, objective statements.
[386]2. NAME OF EMPLOYING FIRM OR AGENCY
[388](CENTURY ELECTRIC COMPANY!
[390]c E é (74 {v1
[391]4. KIND OF SUSINESS f v
[392]MAVAFACTURER OF MOTORS. GENENB TOES » ETC. Aff “a fe: f pox fi
[394]as
[397]%. DESCRIPTION OF DUTIES Toa PRongre AND Shyer THE SALE SA CEvr’R MoTORS, GEV ERG TORS,
[398]4VD RECATED §Qia Pheer in THE TERA re RY 2f CUA, Bb To WOPERRTE mw COLLECT ions
[399]WHEY NECESSARY, T2 IANAGE THE HAVANA WSTRCT Sag és Otte 1 FULL PESPENSA BIT Y (NV
[401]HE ABSENCE of THE Dxsrerer~ MGR. Tt KK ASTER THE a PIRES OF Cay tity ELEC. Ce) NNER
[402]10, REASONS FOR LEAVING 7
[404]—_ PRESENT Com Tiows (W¥ CuBR Med RECEPTAYCE) ASSIGNMENTS
[405]: . re - - : :
[406]OS Pevcep. Ween (Vv CXEA FoR C.I.A. °
[408]SECTION IX CONTINUED TO PAGE 6
[410]14-0000
[412]j 1. INCLUSIVE DATES (From and To - By Mo. and Yr.)
[414]3. ADDRESS (No., Sereef, City, State, / f
[416]a ~ . -~
[417]ST CHARLES : WEW ORLE
[418]S. NAME OF SUPERVISOR
[420]4. KIND OF BUSINESS : f
[421]veces de ek Ee
[423]6. TITLE OF JOB 8. CLASS. GRADE (If Federal Service)
[425]Geaduate Asst [s geo [PER Ayo td byl
[427]9. DESCRIPTION OF DUTIES
[428]TEACHER oF BEGINNER had INTERMEDID-TED SPANISH a THE
[429]CoLheGk LEVEL. 1b ASSIST Wingy Reis TRATI04" BND DECARTAMENTAL Funeri ons,
[431]10. REASONS FOR LEAVING
[433]Je ACCEPT ABOVE PosiTion
[435]+. INCLUSIVE DATES (From and To - By Mo. and Yr.)
[437]SuUWwe /F
[439]3. ADORESS(No., Street, City, State, Country)
[440](ZW TERWA TIONAL TRADE MART NWEWw Crt EAWVS , LA, 4-S-
[441]ECTER
[443]4. KIND OF BUSINESS S. NAME OF SUPERVISOR
[444]LANGURGE  SCHeOe My. HALL, Dew ;
[445]6. TITLE OF JoB | _7. SALARY OR EARNINGS 8. CLASS, GRADE (If Federal Service)
[446]THo FESSOR . A
[448]8. DESCRIPTION OF DUTIES To TEACH THE SPAMS tf LAN. 4 BERLITZ ME THoDd on
[450]10. REASONS FOR LEAVING
[452]Te ACCEPT #FEOVE RSITION AND PARSU
[453]AV ADVANCED DEGREE
[455]1. INCLUSIVE DATES (From and To - By Mo. and Yr.)
[457]JAW: /4F4F — 4 19
[459]3. ADDRESS (No., Street, City, State, Country)
[461]ANE Ave. a Aus Lf. . 5.4.
[463]{Tac a z A
[464]4. KIND OF BUSINESS 5. NAME OF SUPERVISOR ete et
[466]MEDICAL Stspoe De. Wee
[467]6. TITLE OF JOB ®. CLASS. GRADE (If Federal Service)
[469]Metical Kestwtch fechuidtan $ 200-70 |PER pyera |
[471]9. DESCRIPTION OF DUTIES | \ oe
[472]WY CHBRGE 4F SPECTRO pile TOMETRIC AWALYSIS WM THE CARDIO —
[473]VASCULAR RESERRCY “4A GBORBTO ay.
[475]2. NAME OF EMPLOYING FIRM OR AGENCY
[477]_TALANE UNIVERSITY MEDICAL SCHooL
[478]TY
[480]10. REASONS FOR LEAVING
[482]CONCLUSION OF RESEAR CY
[484]1. INCLUSIVE DATES (From and To - By Mo, and Yr.) 2. NAME OF EMPLOYING FIRM OR AGENCY
[485]3. ADDRESS (No., Street, City, State, Country)
[487]4. KIND OF BUSINESS 5S. NAME OF SUPERVISOR.
[488]6. TITLE OF JOB -- 7. SALARY OR EARNINGS 8. CLASS. GRADE (If Federal Service)
[489]$ [Per |
[490],
[492]r SECTION IX CONTINUED TO PAGE 7 -
[496]14-0000 boots. om
[498]9. DESCRIPTION OF, DUTIES
[500]10. REASONS FOR LEAVING
[501]1. INCLUSIVE DATES (From and To - By Mo. and Yr.) 2. NAME OF EMPLOYING FIRM OR AGENCY
[502]- ADORESS (No., Street, City, State, Country)
[503]. KIND OF BUSINESS 5. NAME OF SUPERVISOR
[504]. TITLE OF JOB 7. SALARY OR EARNINGS 8. CLASS. GRADE (If Federal
[506]Service)
[508]- DESCRIPTION OF DUTIES
[510]10. REASONS FOR LEAVING
[511]1. INCLUSIVE DATES (From and To - By Mo. and ¥r.) 2. NAME OF EMPLOYING FIRM OR AGENCY
[512]3 ADDRESS (No., Street, City, State, Country)
[514]4. KIND OF BUSINESS 5. NAME OF SUPERVISOR
[516]6. TITLE OF JOB 7. SALARY OR EARNINGS B. CLASS. GRADE (If Federal
[517]Service)
[519]9. DESCRIPTION OF DUTIES
[521]10. REASONS FOR LEAVING
[523]IF PRIOR SERVICE WITH THE FEDERAL GOVERNMENT IS NOTED ABOVE, INDICATE THE
[524]NUMBER OF YEARS CREDITABLE TOWARD U.S. CIVIL SERVICE RETIREMENT, iF KNOWN.
[526]HAVE YOU EVER BEEN DISCHARGED OR ASKED TO RESIGN FROM ANY POSITION. Cres Bano
[527]HAVE YOU LEFT A POSITION UNDER CIRCUMSTANCES WHICH YOU DESIRE TO EXPLAIN? Cres B<gJNo
[528]IF YOUR ANSWER TO EITHER OR BOTH QUESTIONS !S “YES®, GIVE DETAILS
[531]14-0000
[533]SECTION X . MILITARY SERVICE
[534]_ : 1, CURRENT DRAFT STATUS
[536]1. ARES YOU REGISTERED FOR THE DRAFT UNDER TS) 2. SELECTIVE SERVICE CLASSIFI-
[537]THE UNIVERSAL MILITARY TRAINING AND CATION “4 Fr
[539]3. SELECTIVE SERVICE NO. .
[540]SERVICE ACT OF 1948 (Ae,amended) 16-US-2§9- $3.
[541]4. IF DEFERRED, GIVE REASON D
[543]DIABETES MELL/ THs
[545]2. MILITARY SERVICE RECORD
[546]|. CURRENT AND/OR PAST ORGANIZATIONAL MEMBERSHIP
[548]COAST |MERCHANT) NATIONAL/AIR NAT*L| FOREIGN ORGAN. OR MIL.
[550]CHECK (xX) AS
[551]MARINE | SERVICE (Specify):
[553]APPROPRIATE
[555]MARINE
[556]ARMY NAVY CORPS
[558]3. DATE SEPARATED FROM EXTEN
[560]FORCES (Past and/current service)
[562]6. TOTAL LENGTH A
[563]jeans
[564]7. RANK, GRADE or | Past reas CURRENT SERVICE 8. fSERVICE, SERIAL OR FILE NUMGER (If now serving, provide cur
[565]/rent number)
[566]9. PRIMARY MILITARY OCCUPAYIONAL T SERWICE CURRENT SERVICE
[567]SPECIALTY (Mos or Designatog) AND TI
[568]10. SECONDARY MIL. '* EEECURAR is Sten JONAL pereeevce SERVICE CURRENT SERVICE
[569]SPECIALTY '* EEECURAR is Sten or Designgtor) AND
[570]TITLE
[572]11. BRIEF DESCRIPTION OF pt current service)
[574]f
[576]i
[577]PAST SERVIG CURREMT SERVICE
[579]ha oury/(Paet servicd) 4. TOTAL LENGTH OF EXTENDED ACTIVE OUTY IN U.S. ARMED
[581]S. DATE ENTERED F ACTIVE DUTY IN FOREIGN MILITARY OR-
[583]ACTIVE DUTY op
[585][RETIREMENT FoR ofavice’ a | _[unovenanoonips —OOSSSCS~S~S
[586][_[sELEAEE re nacre gory | [reviews ron fluor oangiey
[587]P[RermenenT ronace | [Retinewent ron/pn|ficat oWsipiry — |
[589]3. MILITARY RESERVE, NATIONAL GUARD AND ROTC STATUS
[591]1, DO YOU NOW HAVE 2. ARE, YOU NOW A MEMBER, OF THE 3. ARE YOU NOW A MEMBER OF | [ves |
[593]RESERVE STATUST
[595][><jno | ska
[596]4. IF YOU HAVE ANSWERED “YES” TO ITEMS 1,2 OR 3 ABOVE, CHECK COMPONENT MEMBERSHIP BELOW
[597]BER
[598]PRavy fain once [fain wareouand [army noye | [ayerance neve
[599]5. CURRENT RANK, GRADE OR [& Rang OF aPromrhewr w of TION DATE OF CURRENT RESERVE OBLIGA-
[600]N
[602]8. CHECK (x) CURRENT RESERVE CATEGORY ae ee,
[603]9. PRIMARY MILITARY OCCUPATIONAL SPECIALTY (Mg D 10. SECOND ITARY OCCUPATIONAL SPECIALTY (Moa or Des-
[604]LE.
[606]12. CHECK (%) TYPE OF SEPARATION FROM ACTIVE DUTY
[607]13, CHECK (x) COMPONENT IN WHICH YOU SERVED
[608]fRecutar | | RESERVE (Including the National and Air National Guard) | | OTHER (Including AUS)
[609]{ YES OTCT
[610]NAT'L. GRD. OR AIR NAT'L. THE ROTC —-,
[611]<[xo | P><Jxo |
[612]mn ARINE CORPS | naTionateuang [1 COASTGUARD, | NAVY ROTC INDICATE ROTC CATEGORY NUM
[613]RATE
[614]ctive)| —_ [STANDBY(Inactive)| | RETIRED
[616]nétor) AND TITLE ignator,
[618]‘1. BRIEF DESCRIPTION OF MILITARY RESERVE DU
[620]12, ARE YOU CURRENTLY ASSIGNED OR ATTACHED YES | 13. 1F you HAVE. ANSWERED "YES" TO ITEM 12, GIVE UNIT OR AGENCY
[621]TO A RESERVE, NAT'L. GUARD OR ROTC TRAIN- AND ADDRESS
[622]ING UNIT xX [No
[624]14. HAVE YOU A MILITARY MOBILIZATION ASSIGN- Mi 1s. Feo HAY wie ial TO ITEM 14, GIVE UNIT OR AGENCY
[625]Lx] xo | a
[628]m
[629]z
[630]4
[634].
[636]16. INDICATE TOTAL MILITARY SERVICE] YEARS 17. WHERE Aq OUR An/SERvt FE RECORDS KEPT
[637]FOR LONGEVITY PURPOSES INCLUD-
[638]ING ACTIVE AND INACTIVE DUTY
[640]a
[642]| rt = a RTO Ret in ee en ee ne a ener anaeepeensin eee
[644]14-0000
[646]1. ARE YOU ENTIRELY DEPENDENT ON YOUR SALARY? Dd ves imc
[647]2. IF YOUR ANSWER IS “‘NO" TO THE AGOVE, STATE SOURCES OF OTHER INCOME
[649]3. BANKING INSTITUTIONS WITH WHICH YOU HAVE ACCOUNTS
[651]4. HAVE YOU EVER BEEN IN, OR PETITIONED FOR, BANKRUPTCY, Pa
[652]S. IF YOUR ANSWER IS “*YES*’ TO THE ABOVE, GIVE PARTICULARS, INCLUDING COURT AND DATE(S)
[654]WA.
[655]6. GIVE THREE CREDIT REFERENCES IN THE UNITED STATES “
[656]ome ADDRESS (Wow, Siroct, Gli Sat)
[658]7. 00 YOU RECEIVE AN ANNUITY FROM fHE UNITED STATES OR OISTRICT OF COLUMBIA GOVERNMENT UNDER ANY RETIREMENT
[659]ACT, PENSION, OR COMPENSATION FOR MILITARY OR NAVAL SERVICE? Cl Yes NO
[661]8. IF YOUR ANSWER IS “YES"* TO THE ABOVE QUESTION, GIVE COMPLETE DETAILS
[663]NA.
[665]9. DO YOU HAVE ANY FINANCIAL INTEREST IN, OR OFFICIAL CONNECTIONS WITH NON-U.S. CORPORATIONS OR BUSINESSES; OR IN
[666]OR WITH U.S. CORPORATIONS OR BUSINESSES HAVING SUBSTANTIAL FOREIGN INTERESTS?
[668](3 res Rt no (If anawer “YES*, tumieh details on acparate sheet.)
[670]SECTION XII . : MARITAL STATUS : '
[671]1. PRESENT STATUS (Single, Married, Widowed, Separated, Divorced, or Annulled) SPECIFY: mM G R ,
[673]2. STATE DATE, PLACE, AND REASON FOR ALL SEPARATIONS, DIVORCES OR ANNULMENTS
[676]WIFE, HUSBAND If you have been married more than once - including annulments - use a separate sheet for former wife or
[677]OR FIANCE: husband giving data required below for all previous marriages. If marriage contemplated, fill in appropriate
[678]information for fiance.
[679]3. NAME . (Firat) : ; . . _ . (Last) oo.
[680]“PRULINE )  . JuUANITA Ross _ RoDRiGUEz’ ;
[682]4. STATE ANY OTHER NAMES EVER USED “INDICATE CIRCUMSTANCES (including length of time) UNDER WHICH ANY
[684]; OF THESE NAMES WERE USED. IF LEGAL CHANGE GIVE PARTICULARS
[686]. 4: (Where and by what authority). USE EXTRA SPACE PROVIDED ON PAGE !6
[687]auth, CNIcKWAME SINCE Chit eod)
[689]5. DATE OF MARRIAGE
[691]OF THIS FORM TO RECORD THIS INFORMATION.
[692]SUV (6.
[694]7, HIS (OR HER) ADDRESS BEFORE MARRIAGE (No.,
[696]39°C Obku
[697]9 OATE OF DEATH 10. CAUSE OF DEATH
[699]pe tiving
[700][<Tres [xo VA.
[702]11. CURRENT ADDRESS (Give last addreaa, if deceased)
[704]L$36/ Silos (16 St, ARERRINE $7.~ FLA
[706]12. OATE OF BIRTH 13. PLACE OF BIRTH (City, Stato, Country)
[708]SAN. 4,4 F _806GALUS A - SA,
[709]SECTION XII CONTINUED TO PAGE 10
[713]MA. °
[715]aS.A.
[717]14. CITIZENSHIP
[719]“4.5.4.
[724]‘ . = + SECTION XH CONTINUED FROM PAGE 9
[726]: . ry 14. IF BORN OUTSIDE U.S. OATE OF EWTRY 15. PLACE OF ENTRY
[727]. WN. 4 . MN. 4 .
[728], : 17. -S. CIT! P| 18. wH City, St
[729]16. FORMER CLTIZENSHIP(S)  [Couner(ies)7 7 DATE US. C TIZENSHI WHERE aa ity, State, Country)
[730]WA. v4. ° A.
[732]20. PRESENT EMPLOYER (Also give former ompto: if, or ife e de
[733]19. OCCUPATION unemployed give last tws employers) mploye: Pouse deceased or
[735]WA.
[737]HOUSE WEE
[739]2t. EMPLOYER’S OR BUSINESS ADDRESS (No., Street, City,
[741]State, Country)
[743]22. DATES OF MILITARY SERVICE (Froan and to - By Mo. and Yr.)
[745]23. BRANCH OF SERVICE 24,
[747]COUNTRY WITH WHICH MILITARY SERVICE AFFILIATED
[749]N-A. LAE
[751]25. DETAILS OF OTHER GOVERNMENT SERVICE, U.S. OR FOREIGN
[753]Nw. FA.
[754]. e PS ECTION AI ICSE FATTO DREN AND OTHER DEPENDENTS] xt CHILDREN AND OTHER DEPENDENTS
[755]1. PROVIDE THE FOLLOWING INFORMATION FOR ALL CHILDREN AND DEPENDENTS
[756]| —__Naws___[ ek aTionstiP [PATE AnD PLAGE oF euern [eifizenanie | —haonaas ———
[758]- — “GIEl SWITE ST
[759]|Euteto Ameaieo novRiauer I-R-) ale | aca. LELRINE S7, FLA.
[761]36f Sh. 7
[762]PATTI MICHELLE Rorkiquet) | PAUGTKE ;
[764]etd a LA
[765]; $360 SW. (79 ST.
[766]ace zi 2 huh iy f PERRINE S72, ELK:
[768]NDENTS (Including epouse,
[769]parents, etep-parents, sister, otc.) WHO DEPEND ON
[771]YOU FOR AT LEAST 50% OF THEIR SUPPORT, OR
[772]CHILDREN OVER 21 yrs, OF AGE WHO ARE NOT
[775]2. CH firenand, enitiptodt a Beet ARE
[778]UNMARRIED, UNDER 2t YRS OF AGE,
[779]AND NOT SEL F-SUPPORTEG.
[781]; ; 3. DATE OF DEATH 4. CAUSE OF DEATH
[782]ft. FULL NAME (Last-Firet-Midile) ; [ 2 twine |
[783]wDRIGKEZ, Akwes7s NEPOLEON, Sires [no Wh. wae
[785]INDICATE CIRCUMSTANCES (neluding length of fime) UNDER WHICH HE HAS
[787]EVER USED THESE NAMES, IF LEGAL CHANGE, GIVE PARTICULARS (Where
[788]and by what authority). USE EXTRA SPACE PROVIDED ON PAGE 16 OF THIS
[789]FORM TO RECORD THIS INFORMATION, -
[791]6. CURRENT AODRESS - Give imet editrese, if deceased (No., Street,
[793]The Otleauvan fh -rtet ST
[794]OE. Havas
[796]0 et mere = 7
[797]ca 10. IF BORN OUTSIDE U.S. -IJATE OF ENTRY
[798]: Neu. /fér
[800]12. FORMER CITIZENSHIP(S) Coutry{les)7 18. DATE U.S. CITIZENSHIP
[802]N.A. ACQUIRED! W4
[804]"1. PLACE OF ENTRY
[806]13. OCCUPATION
[808]RETIRED
[810]20, COUNTRY
[812]WA.
[814]We#. MN.
[816]RI. DETAILS OF OTHER GOVENMEST SERVICE, U.S. OR FOREIGN JYTELLIGECE
[817]MAVAWA C2gn Duke wend whk Tweeter wee
[820]14-0000
[822]1. FULL NAME (Last-Firat-Middle)
[823]EN yg
[825]4. CAUSE OF DEATH
[827]ITE IOS LRG Ss
[828]£ of time) UNDER WHICH SHE HAS
[829]EVER USED THESE NAMES. IF LEGAL CHANGE, GIVE PARTICULARS (Where
[830]and by what authority). USE EXTRA SPACE PROVIDED ON PAGE 16 OF THIS
[831]FORM TO RECORD THIS INFORMATION,
[833][\CASaNovAR
[835]6. CURRENT ADDRESS - GIVE LAST ADORESS,
[837]the Gt fenvian hgh fel $7
[839]9. CITIZENSHIP
[841]Cohen
[843]DATE OF ENTRY
[845]hot ffs0
[847]FORMER CITIZENSHIP(S) LCountry(tee)7
[849]W-
[851]New Or lear,
[853]CITIZENSHIP
[855]ELE
[857]18. OCCUPATION 16. PRESENT EMPLOYER (Give last employer,
[859]Hfetsewu KE M8,
[860]EMPLOYER'S BUSINESS ADDRESS OR MOTHER'S BUSINESS ADDRESS IF SELF EMPLOYED
[862]WA.
[864]19, BRANCH OF SERVICE 20. COUNTRY
[866]WA, MA) .
[867]U's
[869]Sp. MAIL) CENSCR 1 NEW COLERYS
[870]CEVSORSHIP OFFICE DakiIngG wenLd WAR IW
[872]13. DATE U.S,
[874]ACQUIRED
[876]if Mother ie deceased or unemployed
[878]DATES OF MILITARY SERVICE (From-and-To)
[880]21. DETAILS OF OTHER GOVERNMENT SERVICE, U.S. OR FOR
[882]SECTION XVI BROTHERS AND SISTERS (Includin,
[883]aD FULL NAME (Laat-F iset-Middle)
[885](Remkieuex, ARNESTS Tose,
[886]4. CURRENT ADDRESS (No., Street, City, Zone, State, Country)
[888]‘2/2_ MgPE Rd. Metaie Lg. USA.
[890]{. FULL NAME (Last-Firet-Middie) 2. RELATIONSHIP
[892]& Half, Step- and Adopted Brothers and Sisters)
[894]2 RELATIONSHIP 3. CITIZENSHIP (Country)
[895]Bho THER. U.S.
[896]S&S. LIVING &. AGE
[897][res T [xo] 38
[899]3. CITIZENSHIP (Country)
[901]4. CURRENT ADDRESS (No., Street, City, Zone, State, Country) 8. LIVING
[904]2. RELATIONSHIP 3. CITIZENSHIP (Country)
[906]2. RELATIONSHIP : é
[908]2. RELATIONSHIP 3. CITIZENSHIP (Country)
[910]8. LIVING
[912]2. RELATIONSHIP 3. CITIZENSHIP (Country)
[914]5. LIVING
[916]2. RELATIONSHIP 3. CITIZENSHIP (Country)
[918]5. LIVING
[920]/2, RELATIONSHIP 3. CITIZENSHIP (Country)
[922]+ FULL NAME (Last-First-Middle)
[924]4. CURRENT ADDRESS (Wo., Street, City, Zone, State, Country)
[926]1. FULL NAME (Laat-Firat-Middte,
[928]4. CURRENT ADDRESS (No., Street, City, Zone,
[930]State, Country)
[932]1. FULL NAME (Laat-F irs t-Middle)
[934]4. CURRENT ADORESS (No.,
[936]Street, City, Zone, State, Country)
[938]FULL NAME (Laet-First-Middie)
[940]4. CURRENT ADDRESS (No.,
[942]Street, City, Zone, State, Country)
[944]1. FULL NAME (Laet-First-Middle)
[946]‘4. CURRENT ADDRESS (No., Street, City, Zone, State,
[948]ls FULL NAME (Laat-F irat-Middle)
[950]+ CURRENT ADDRESS (No., Strost, City, Zone, State, Country)
[952]-N-
[954]14.90000
[958]ECTION Xviq FATHER-IN-LAW
[959]ae “FULL NAME (Laat-Firet-Middie) = 2. LIVING 3. DATE OF DEATH 4. CAUSE OF DEATH
[961]“HOSS , SAmuez SANFoRD i | T BI | tunes He?) EART A
[963]'3. STATE OTHER NAMES RE HAS USED INDICATE CIRCUMSTANCES (Including length of time) UNDER WHICH HE HAS
[965]. EVER USED THESE NAMES. IF LEGAL CHANGE, GIVE PARTICULARS (Where
[966]id by what authority). USE EXTRA SPACE PROVIDED ON PAGE 16 OF THIS
[967]AM (wkwaye scarce ChieDW00d) | 2
[968]6. CURRENT OR LAST ADDRESS (No., Street, City, State, Country)
[970]FORM TO RECORD THIS INFORMATION.
[971]‘PReeute 2 Box so EDENTON, W.C.)
[973]] 8. PLACE OF BIRTH (City, State, Country)
[975]“Me Bree) ALABAMA, tt-$.
[977]-S.- DATE OF ENTRY M1. PLACE OF ENTRY
[979]“Sf.
[981]9. CITIZENSHIP
[983]“Y-S-A.
[985]IF BORN OUTSIDE U
[987]FORMER CITIZENSHIP(S) ZCountry(iee)? 13. DATE U.S. CITIZENSHIP 14, WHERE ACQUIRED (City, State, Country)
[988]ACQUIRED :
[989]. . vf . ALA.
[991]1S. OCCUPATION
[993]SIwvyeeR
[995]16. PRESENT EMPLOYER
[997]‘RP BAER
[999](Give tast employer, If Father-in-Laew is deceased or imemployed)
[1001]WD Co, EVEN TON)
[1003]3. DATE OF DEATH
[1005]LX] ves T [se] m4.
[1007]INDICATE CIRCUMSTANCES Cncluding tength of time) UNDER WHICH SHE HAS
[1008]EVER USED THESE NAMES. IF LEGAL CHANGE, GIVE PARTICULARS (Whero
[1009]and by what authority), USE EXTRA SPACE PROVIDED ON PAGE 16 OF THIS
[1011]FORM TO RECORD THIS INFORMATION.
[1013], Street, City, State, Country)
[1014]Heute 2, Box Svo, EDEN TON) Me.
[1015]ra DATE OF BIRTH 8. PLACE OF BIRTH (City, State, Country)
[1016]Dec. BI IF FF’ ZLAKREL |) Mss.
[1018]10. IF BORN OUTSIDE U.s. 1t. PLACE OF ENT
[1020]RY
[1021]MA.
[1022]13. DATE Us. CITIZENSHIP
[1024]ACQUIRED WA.
[1025]16. PRESENT EMPLOYER (Give last employer,
[1026]Mt, A.
[1028]BLOOD, MARRIAGE OR ADOPTION WHO EITHER QQ) Live ABROAD,
[1029]U.S. CITIZENS OR (3) WoRK FOR A FOREIGN GOV ERNMENT
[1031]2. RELATIONSHIP
[1033]SISTER (W LAW
[1035]CaSElWOs FE
[1037]RELATIVES BY
[1038]SECTION xix . (2) ARE NOT
[1040]1 FULL NAME {Last-Firet-Middle)
[1042]‘LOPEZ ELEWA
[1044]4. ADDRESS OR CO NTRY IN WHICH RELATIVE RESIDES
[1046]le P ¢
[1047]2/2 Mare RA. Mer
[1048]6. CITIZENSHIP (Country) 7. FREQUENCY OF CONTACT 8. DATE OF LAST CONTACT
[1049]MEXICAN MCE EARL lyf) DUNE SFE
[1050]; ; 2. RELATIONSHIP Peace]
[1051]t. FULL NAME (Last-Firat-Middie)
[1053]- EMPLOYED By
[1054]4. ADDRESS OR COUNTRY IN WHICH RELATIVE RESIDES
[1056]7. FREQUENCY OF CONTACT 8. DATE OF LAST CONTACT
[1058]2. RELATIONSHIP
[1060]5. EMPLOYED By
[1061]» DATE OF Last CONTACT
[1063]2. RELATIONSHIP . pee]
[1065]- EMPLOYED By
[1067]6. CITIZENSHIP (Country) 7. FREQUENCY OF CONTACT
[1068]'. FULL NAME (Laet-Firet-Middie)
[1069]4. ADDRESS OR COUNTRY IN WHICH RELATIVE RESIDES
[1072]SECTION XIX CONTINUED TO PAGE 13;
[1075]14-0000
[1077]SECTION XIX CONTINUED FROM PAGE 12
[1078]6. SPECIAL REMARKS, IF ANY, CONCERNING RELATIVES NOTED IN SECTION XIX ABOVE
[1080]Above nelalive has bees a Covtewuocuas Resident in the US.8. Sthee (E¢5- 6, Mew
[1082]Ppleins 4h,
[1084]RELATIVES BY BLOOD, MARRIAGE OR ADOPTION WHO ARE IN THE MILITARY OR CIVI
[1085]SECTION XX SERVICE OF THE UNITED STATES .
[1087]6. TYPE AND LOCATION sie SERVICE (If Town)
[1089]MUAQUNE P/LOT AND (gtr Gane US TRUCTOR
[1090]¢ FEASA COCA a FU AL env
[1091]2. RELATIONSHIP
[1093]4. CITIZENSHIP
[1095]6 TYPE AND LOCATION OF SERVICE (If known)
[1097]4. CITIZENSHIP
[1098]6. TYPE AND LOCATION OF SERVICE (it known)
[1100]REFERENCES, ACQUAINTANCES, AND NEIGHBORS
[1101]1, LIST FIVE CHARACTER REFERENCES, NOT RELATIVES, IN THE U.S., WHO KNOW YOU INTIMATELY
[1103]2. RELATIONSHIP
[1105]BUSINESS ADDRESS
[1106](No., Street, City and State)
[1108]ADe p
[1109]Pesident, dl g
[1111]A Mes: WOOD _ “Ss.
[1113]BUSINESS ADDRESS
[1114](No., Street, City and State)
[1116]RESIDENCE ADDRESS
[1117](No., Street, City and State)
[1119]EBASCO SERUICES , MY.
[1120]GNk.
[1122]COWL SERVICE
[1124]- J. BRu NO.
[1125]Denorny BeETTCHER)
[1127]HEeasS Ew rE
[1129]. BUSINESS ADDRESS RESIDENCE ADDRESS
[1130](Last-Firat-Middle) (No., Street, City and State) {(No., Stroot, City and State}
[1132]Pec bles en clone ta
[1133]mm. é. Pee f Wlw @, A Vew Galen res UF i
[1134]RE PRED | S72 pt war Se
[1135]7. Whi Le ere, SEANCE News Cale ,
[1136]‘THANE UMIVERS ITY
[1137]Sowishe Dapnanieny ak.
[1142]14-0000
[1146]‘ e SECTION XXII CLUBS, SOCIETIES, AND OTHER ORGANIZATIONS
[1147]. rattle
[1148]° NOTE: List names and addresses of all clubs, societies, professional societies, employee groups or organizations of any kind
[1150](Include membership in, or support of, any organization having headquarters or branch in a foreign country) to which you
[1151]belong 6r have belonged.
[1153]DATES OF MEMBERSHIP
[1155]NX
[1156]bY
[1157]y
[1159]AODRESS
[1160]NAME AND CHAPTER (Number, Street, City, State, Country)
[1162]TULAWE (AM UERSITY
[1164]SFS1
[1165]4 fe. on .
[1166]DE PRUw )UNLVERS TTY
[1168]fmenicad Ms. of laces, « ba tush ¢ fa aie tn ke
[1171]Ph, S4 MA Lor
[1173]e RESIDENCES FOR THE PAST 15 YEARS
[1174]ADDRESS - LAST RESIDENCE FIRST
[1176](Number, Street, City, State, Country)
[1180]CFS 7
[1183]14-0000
[1185]a
[1187].
[1188]. td
[1191]a)
[1193]t
[1195]@ | SECTION XXIV : ADDITIONAL INFORMATION
[1196]ra -
[1197]1. OO YOU ADVOCATE OR HAVE YOU EVER ADVOCATED; OR ARE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF;
[1198]OR HAVE YOU EVER SUPPORTED OR BEEN ASSOCIATED WITH ANY POLITICAL PARTY. INDIVIDUAL OR ORGAN -
[1199]IZATION WHICH ADVOCATES OR TEACHES THE OVERTHROW OF THE GOVERNMENT OF THE UNITED STATES BY
[1201]FORCE, VIOLENCE OR OTHER UNCONSTITUTIONAL MEANS, OR SEEKS BY FORCE OR VIOLENCE TO DENY PERSONS K\/
[1202]THEIR RIGHTS UNDER THE CONSTITUTION OF THE UNITED STATES? . ‘A
[1204]2. 1F YOU HAVE ANSWERED “YES” TO THE ABOVE QUESTION, EXPLAIN
[1206]N.A.
[1208]YES 4. IF SO, TO WHAT EXTENT?
[1209]» OVER USED INTOXICANTS?
[1210]VER USED TS ol
[1211]XT ne Nt
[1212]YES 6. IF SO, TO WHAT EXTENT?
[1213]5. DO YOU USE OR HAVE YOU
[1214]EVER USED NARCOTICS? Sino | N-f-
[1215]7. HAVE YOU EVER BEEN A MEMBER OF, OR SUPPORTED, OR HAD ANY CONNECTIONS WITH A FOREIGN INTELLIGENCE ORGAN-
[1216]IZATION OR ITS ACTIVITIES? 5 ¢
[1217](ves. [X]No IF ANSWER IS “YES*, GIVE COMPLETE DETAILS.
[1219]wh.
[1221]8. SEO MENT SINCE NAMES OF GOVERNMENT DEPARTMENTS, AGENCIES OR OFFICES TO WHICH YOU HAVE APPLIED FOR EM-
[1222]C.D.A., STATE DEPARTMENT, Pan AME MER Union, Cry SERVICE,
[1224]USTA.
[1225]9. IF TO YOUR KNOWLEDGE, ANY OF THE ABOVE HAVE CONDUCTED AN INVESTIGATION OF YOU, INDICATE THE NAME OF THE
[1226]AGENCY AND THE APPROXIMATE DATE OF THE INVESTIGATION.
[1228]UNK.
[1230]NOTE SPECIAL| If your answer is “YES* to the following Questions 10, 11 or 12, provide the information requested for each
[1231]INSTRUCTIONS | question on a separate, signed sheet and attach the sheet to this form in a sealed envelope. :
[1232]| YES
[1234]| vee
[1236]YES
[1238]10. HAVE YOU, OR TO YOUR KNOWLEDGE HAS YOUR SPOUSE, EVER BEEN DETAINED, ARRESTED, INDICTED OR CON-
[1239]Weer ANY VIOLATION OF THE LAW OTHER THAN A MINOR TRAFFIC VIOLATION IN THE UNITED STATES OR
[1241]IF SO, STATE NAME OF COURT, CITY, STATE, COUNTRY, DATE, NATURE OF OFFENSE AND DISPOSITION OF CASE
[1242]IN ACCORDANCE WITH THE SPECIAL INSTRUCTION ABOVE.
[1246]11. HAVE YOU EVER BEEN ARRESTED, COURT-MARTIALED OR OTHERWISE PUNISHED UNDER MILITARY LAW OR REG-
[1247]ULATIONT IF SO, DESCRIBE INCIDENT(S) AND PROVIDE DATE(S) OF OCCURRENCE ON SEPARATE SHEET IN AC-
[1248]CORDANCE WITH SPECIAL INSTRUCTIONS ABOVE. s
[1250]12. ARE THERE ANY UNFAVORABLE INCIDENTS IN YOUR LIFE, NOT MENTIONED ABOVE, WHICH MAY BE OISCOVEREO
[1251]IN SUBSEQUENT INVESTIGATION, WHETHER YOU WERE DIRECTLY INVOLVED OR NOT, WHICH MIGHT REQUIRE EX-
[1252]PLANATION? 1F SO, DESCRIBE INCIDENT(S) AND PROVIOE DATE(S) OF OCCURRENCE ON SEPARATE SHEE
[1253]CORDANCE WITH SPECIAL INSTRUCTIONS ABOVE.
[1255]><] B<
[1256]a
[1258]@ | SECTION XXV j PERSON TO BE NOTIFIED IN CASE OF EMERGENCY
[1259]1. NAME (Firat-Middfe-Last) 2. RELATIONSHIP
[1261] Phukin€ WTuayitA wt rE
[1263]3. HOME ADDRESS (No., Street, City, Zone, State, Country)
[1264]$360 Sw. (78 St PEARINE S$?) FLA. CEdite~S- §3¢E
[1266]BUSINESS ADDRESS (No., Street, Clty, Zone, State, Country) - INDICATE NAME OF FIRM OR|6. BUSINESS PHONE NO. & EXT.
[1267]EMPLOYER, IF APPLICASLE
[1269]7. IN CASE OF EMERGENCY, OTHER CLOSE RELATIVES (Spouse, Mother, Father) MAY ALSO BE NOTIFIED. IF SUCH NOTIFICATION
[1270]iS NOT DESIRABLE, BECAUSE OF HEALTH OR OTHER REASONS, PLEASE SO STATE.
[1272]AA.
[1276]14-0000
[1279]@ [SECTION XXVI ° CERTIFICATION
[1280]soy
[1281]4 YOU ARE INFORMED THAT THE CORRECTNESS OF ANY STATEMENT MADE IN THIS APPLICATION
[1282]. WILL BE INVESTIGATED.
[1285]4 have read and understand the instructions. | Certify that the foregoing answers are true and correct to the best of m
[1286]knowledge and belief. | agree that any misstatement or omission as to material fact will constitute grounds for imme: iate
[1288]dismissal or rejection of my application. | also understand that any false statement made herein may be punishable by
[1289]faw (U.S. Code, Title 18, Section 1007}.
[1291]- DATE OF SIGNATURES
[1292]Seth S, [FES
[1294]3. SIGNED AT (City and State)
[1296]Mihm, FR.
[1298]NOTE: Use the following space for extra details. Reference each continued item by section and item n SKich it relates
[1299]sign -your name at the end of the added material.
[1300]page and sign each such page.
[1302](
[1303]If additional space is required use extra pages the same size as this