Document Type: 
Document Number (FOIA) /ESDN (CREST): 
Release Decision: 
Original Classification: 
Document Page Count: 
Document Creation Date: 
June 22, 2015
Document Release Date: 
April 17, 2008
Sequence Number: 
Case Number: 
Publication Date: 
October 30, 1957
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~~~ P~RlUO1C SUPPL~ME~ THIS DATE (b) (3 ) ~ C u ~i'f~~'~' ~~~'~ b~~ ~ `w,'- INST ROCTIOPlS This for,n provides the means whereby your oFficial personnel records will be kept current. Even though it duplicates in iermation you have furnished previously, ii wiil be necessary fct you to~ complete Sections 1 through VI in their entirety. You need complete Sections VFI f,hrough XI77 on Cy if There has been a change since you enPered on duty with the organizstion or if you believe the item requires .more complete coverage Then you have previously reported. GENERAL I . FU 2. CURRENT ADDRESS (No. Street, City, Zone, State) ~ ,,. PERMANENT ADDRESS (No. Street, City, Zone, State) L3,{~ v~.E~ ~~L'al.'.b'r,F L'.O'r,.SL~.s ~=Ox,S1C1CL~.C1A~ 1it3i't~i ~117 ~2."!?~ .' . 4. HOME TELEPHONE NUMBER 5? STATE, TE P,RI TORY, POSSESSION OR COUNTRY IN WHICH YOU NOW CLAIM RESIDENCE ~~.lexxci~:.~~ ~-~2~:~ C~'~ ~m~ tilt>?~ SECT!GN II PERSGN TG 9E NGTlFIED tN CASE GF EMERGENCY 1. NAME (Last-~'i rs t-'7i ddle) PREFERABLY RESIDING IN U.S. 2~ RELATIONSHIP 19~~~ 3? HO 0 ESS~~~Yo. Greet, t y, one, Sta 1'e, Covn try). 4. BUSINESS ADDRESS (No. J'treet, City, Zone, State, Court ry)? INDICATE NAME OF FIRM OR EMPLOYER, IF APPLICABLE 5~.158~ 5? HOME TELEPHCNE NUM BER o~ BUSINESS TELEPH U'NE NUMBER 7. BUSINESS TELEPHONE EXTENSION 3~ IN CASE OF EMERGENCY, 07H ER CLOSE RELATIVES (Spouse, :No this, Father) MAY AL 50 BE NOTIFIED. IF SUCH NOTIFICATION IS NOT DESIRABLE BECAUSE OF HEALTH OR OTHER REASONS, PLEASE SO STATE. SECTIGN I I I ' a I 1. CHECK (X) ONE: ~ SINGLE ,MARRIED IW!OG WED SEPARATE DIVO RCED ANNIiI LED - 2? FURNISH DATE. PLACE AND REASON FOR ALL SEP A.RATIONS, DIVORCES OR ANNULMENTS ~>~ ~r Ci'1~3,2'!~~5~ SPOUSE: If you fiave been married more Eh an once, including annulments,- use a separate sheet for former wile of husband giving data below for all previous marriages. If marriage is contemplated, provide same data For fiance. 3. NAME First ,Middle) (Maiden) Last) State, Country) 4. DATE OF MARRIAGE 5? PLACE OF MARRIAGE (City ~7 6. ADDRESS OF SPOUSE BEFORE MARR; AGE (No. Street, City, State, Covn try) 'iashirx~tGr.A, CGl~.n~~ti.~r::~ 7. LIVING 8. DATE OF DEATH 9? CAUSE OF DEATH ?~ Y E S Y 0 I I 10. CURRENT P.D DRESS (Give Last address, if deceased) II DATE OF BIRTH 12? PLACE OF BIRTH (City,- State, Co entry) ' fA~ i3? IF BO RDI OUTSIDE U.S.?DATE OF ENTRY 14? PLACE GF ENTRY 4 ~-; , . ~ ~,~, r`. 15 CITIZENSHIP (Country) I6 GATE ACQUIRED li~ WHERE ACQUIRED (Cit p } ~~~ ~ ~ > %rA T L~ u 18~ OCCUPATION ` sad or- 19. PRESENT EMPLOYER (A1 sc give former employer r~iKf,F e3e unemployed, last two employers) ... 20. tMPLOYEP,'S OR BUSINESS ADDRESS (No. Street, Ci Ly, J't ate, Country) SECTiGtt 131 CGNTIN ED TO PAGE 2 FDRM lI `Li(.~ USE PREVIOUi EDITIDNS. 4? si r T T APPROVED FOR RELEASE r41 DATE: FEB 2008 SECTfOk Ill TlNUED FP,OFf PAGE 1 DA7E5 OF MILITARY SERVICE OF SF OUSE (From? ar.d To- ) BY MONTH AND Yf_AR- n ' N~ 22? ERANCH OF SE F.V ICE 23? COUNTRY WITH WHICH MILITARY SERVICE AFFILIATED 24? DETAILS OF OTHER GOVERNMENT SERVICE, U.S. OR FOREIGN SECTION IV RELATIVES BY BLOOD, MARRIAGE OR ADOFTIOk LIVING .dBROAD OR W.HO ARE NOT U.S. C.lTIZENS 1 FULL NAME (Lest-First-Middle) 2? RELATIUNSH IP ?~ -. 3? FGE ~~ ` I 1 4~ HDDRESS OR COUNTRY IN WHICH RELATIVE RESIDES i 5? CITIZENSHIP (Country) 6~ FREQUENCY OF CONTACT 7? DATE OF LAST CONTACT ~ 1 FULL NAME (Last-First-Middle) 2~ RE.L ATIONSH IP 3? AGE 4~ ADDRESS OR COUNTRY IN WHICH RELATIVE RESIDES 2 , i 5? CITIZENSHIP (Country) 6? FREQUENCY OF CONTACT 7~ DATE OF LAST CONTACT 1 FULL. NAME (Last-First-Middle) 2? RELATIONSHIP 3? AGE 0 4? ACDRESS OR COUNTRY 1N' WHICH REL A?[!VE RESIDES 5. C'TIZENSHIP (Country) 6~ FREUUENCY OF CONTACT 7~ DATE OF LAST CONTACT i. FULL NAME (Last-First-Middle) 2? RELATIONSHIP 3? AGE 4? ADDRESS OR COIIN TRI' IN WHICH RELATIVE RESIDES 4 5? CITIZENSHIP (Country) 6? FREQUENCY OF CONTACT 7? DATE OF LAST CONTACT 5? SPECIAL REMARKS, IF ANY, CONCERNING THESE RELATIVES SECTIOk V F1kANCIAL STATUS -1. AP,E Y"OU ENTIRELY DEPENDENT ON YOUR SALARY? ~ 1"=5 ,;p ~ [j e2` ,'S ~ei~~l 2. DO YOU HAVE ANl' FINANCIAL INTEREST IN, OR OFFICIAL CONNECTION WITH, NON?U.S. CORPORATIONS OR BUSINESSES OR IN OR W'I TH U.S. CORPORATIONS OR BUS+INESSES HAVING SU ESTANTIAL FOREIGN INTERESTS? ~ YES ~ NO IF YOU H AVE ANSWERED "YES. '~ GIVE COMPLETE DETAILS ON A SEPARATE SH EE T AND ATTACH IN A SEALED ENVELOPE. 3, Ci? VDU RECEIVE AN ANNUITY FROM THE UNITEC STATES OR DISTRICT OF COLUMBIA GOYER NFdENT UNDER ANY RETIREMENT ACT, PENSION. CR COMPENSATION FOR MILITARY OR LAVAL SERVICE? ~ YES NO 4, IF YOU HAVE ANSWERED ?YES" TD QUESTION ., ABOVE, GIVE COMPLETE DETAILS. ~_ IS. WITFIOUT REFERENCE TO YOUR SALARY, STATE OTHER SOURCES OF RECURRENT INCOME NOT INDICATED BY PRECEDING ITEMS, E Fet,* hund~?od dollaxr ar~l'.~; ~'~.'om ~~Z~zc~.e:~c?t~, p~.tts occa~,icsn~.~. sr~ori 4 aetiv~~ ~i1.~t~.~,T ~.~.,,tiro `s SECTION V GOkTI ED TO PAGE SEC T (When f led In) S?CTlO~i Y CO iNUED FROh PAG? 2 S BANKING INSTITUTIONS WITH WHICH YOU HAVEACCOUN7S NAME OP INSTITUTION AGGRESS (City, State, Country) v.~' In -ria' i 1 -r. v11i~.T O-rC~ ~'Z?'L15 u ~%~A?~)ds".1~' ~Ll~ .1.~'U'x"~'..' ~?'O:r2"io 7 HAVE YOU EVER BEEN IN. Oft PETITIONED FOR. BANKRUPTCY? YES NO g, IP YOU H.4 VE ANSWERED 'YES" TO QUESTION i ABOVE. GIYE PARTICULARS, INCLUDING COURT AND DATE(S) CITIZ&YSNiP I~ COUNTRY OF CURRENT CITIZENSHIP V~ 2~ CITIZENSHIP AC vUiRED BY - CHECK (Xl ONE: f~~'--~-y{ i31RT4 O MARRIAGE ~_I OTHER (SpeCi fy ): 3~ HA4E YOU TAKEN STEPS TOI CHANGE YOIJR PRESENT CITIZENSHIP? ~ rES ~ ND 4~ GIVE PARTICULARS 5? IF YOU HAVE APPLIED FOR U.S. CITIZENSHIP, INDICA T,E PRESENT STATUS OF YOUR APP L-(CATION (First papers, etc.) SECTION NII EDUCATION _ I~ CHECK (X) HIGHEST LEVEL OF EDUCATION ATTAINED LEIS THAN HIGH >CHUOL GAAOUgTE 0`!`c .9 TNO YEARS DF ..^_CLLE 6E -NO DE GAEE HIGH SC.4004 GRADUATE q?. d4 BACHELOR'S ~EGR~E TRADE. RIJGINESS ON COMMERCIAL SCHOOL GRADUATE GRADUATE STUDY LEADING 70 HI 6HER DEGREE T'MC YEARS COLLEGE OA LE55 MASTER`S DEGREE OOC?DR'S DEGREE 2~ CCLLEGE CR UNIVERSITY STUDY SUBJECT DATES ATTENDED DEGREE DATE 5'cM/QTR HRS. PLETED C NAME AND LOCATION CF COLLEGE OR UNIVERSITY MAJOR M!NOA FROM To REC D RECD OM (Specify} f~ ^r~s,~ P I~rl ~t'o ,~~~.~ S:,,C,'y'~:n ry ~~e;,. :~.~?~..~ !!''~~ ~..7 ~ u d~ a~ L711~ '~~ III t 3. TRADE, COMMERCIAL AND SPECIALIZED SCHOOLS DATES ATTENDED TOTAL N.gME OF SCHOOL STUDY OR SPECIALIZATION FROM TO HOURS USA' Inte11< Sck?.,, r~,rx?~.s~us ?a, ~+a~~;:~'~. In~1a ~?off 1~9~2 ',z.~ ~~aeek~ USAF F~3 Sa?x,.clror, & ~e;~?I_x^.n~. c:;5as?scs~ ~:~ren.~.1 ~~L~,erg~~. g ~?br S>en i r (;i~"i~~x~s ottx~e 4~ MILITARY TRAINING (Fu11 time duty in specialized schools such as Ordnance, Intelligence, Communications, etc.} DATES ATTENDED TOTAL NAME OF SCHOOL STU D'f OR SPECIALIZATION FROM TO `NEEKS ~?ris'cu.'~ ;D111~ See