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Document Creation Date: 
June 22, 2015
Document Release Date: 
December 31, 2008
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Publication Date: 
January 1, 1955
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APPROVED FOR RELEASE DATE: 10-Nov-2008 (bl61 (b131 FUH, NAME -~Zat ~A~dl Tc:lcphnne jf/U~f'ST-~''.?P / tny nthr, n-,,,,, u- +f r c no, .J T ? ctrco :;t~ncon D:,tc, .rnd ::c(' of 1-!L - ~k+tfL~1~t,:i7 b~ ~r (/as p b:i ;h By mn.rringe 'T-.. Phyolc:il Prr'^,.ript.ton: Af{c- -__c`-Y- ''v?y. tr2 kS~2~i sir Four, _rcnrs e_ Any d istinguish n fr nti res Full nnn;e ,f '.'Taou;,e Dal, and pl!?c. of i~:tr r Ad'lr :'in;}1c P'srrand Divorced Al nu7.mr.ant iv cc _ Ccruti t.{un cmt ?~,~qC~ o3-rr nn? nddrrss Mil At el",1 r` (.'r.nCh of new co "nd L'I -OK } n j_1~ftT /Fry 6V. 7. / At off c'r ,c?V(U. ` . or nreie: p ni.n tfy4 C'hil.dren ex 'c?n nnm~=, mot. t.i.nnsl i , F; e: ? ?ihd -ri l.. 1 ~ ~ ~ resscs >~ . S'~ ~?~ ~4 dd ~- esr Adri.ro s Pi,nco ru.I dar(, cn bi tls ~~~'T r s _ Jon' thr I" born nuts?.de TT oLef' do+0 f 11d of ontry =~Agc,.1y. /.$'ze )ecup~r-bo~/ ~p LLC.- - 6 Addreaa -,--- P.lnce an {,e } } st d.1'c ~-~_~I.T U,S,. or other born ottts:[do I1,;",, ;;t:t.e date and piece of entr nd -41 y Mother-in- law's full naije ~.attrQ d ./sn ~rera~ 1\d ?ress /(~ ~I aria s f I'lnr.,., & data OF birt}I~' iti en Uor ether ynd If Born outside U., q., sto{.i: deto and place of entry _ `~ Occuu>a tion.// ,?mploycr & eddresq Occurs tierTL~u.ary 1~?[~~n~a., l;mnloyer and address ~ilCa P.ov . k'9. ' VI An,., rulativcas 1.iv:ing ,abroad or who arc. no s r t ;ens of the i t J-13- (M yn 3s ~ Ravave ncuucs rol t1011!7.lon addrr ; Sipe 39e3 7 : : E civil 01, s" V (Give n,tm c, relationship, apes, oddr(,s e sce, and service) ao vuI Eduoation: hli.rr.:ntary school High-School / College RA-0s aiterded P1f me & address of college DiF'reo tits jorr Lit any special. or outside courses pur :u??d not within cull c.ge ct.rri ctt^?tp AI ~ar 777 Active mil.tary- scrvicc, U. , or .fors:-ign(spocify hlnneh of service and dates, lelJ_ d~~LrlG4ec_,,~v z . Give name :?n address of Seicc IV, Serv ~.~J_4y~' o~~O~ ~9Y3 /fr If deferred, givt: rer son Give chronological hi:.tory of em_~lo.r.:,nt for past 10 years. Give nee, 2 address of omtllcyc.rs~ dates, t,r of no^iti.on, salary, reasons for leaving, (If additional. ? en to needed, use reverse side) .G7'- 9~+?~J.~ azL~r ?5~ rleIFe Q fi . ~o , ~7 f~(/~~o ti ? ~? . S~Q/~ rem lr' 9 - 1J.% __ ~` 'TO6 c~b~Q.~~d J,4 1Al oa, . f n * woe'?_ ? Are you in goal c.nltb? be conai.dored in assignin xl~latn any, disab~.l.ities that a.hou .d ._ List any s "''~?--~ ..f- " ~++eI*/ea8e~ pecia7. quali.fiaalons ou t ay have, such as 1angu-gost technical sl;i.lls, or -54 z4Wl ~ ~-- c- gyn..?~ (USs OTiU R RIDE It NECESSARY) 1X G?wc; 5 chaynctcr rcfcrcy)ces in U,S, (not relatives). Give residence- ,~,~P9 ~bo(-zvT 4ue ~.~11~ ~~ZrZ C~Z X711 4 IV 2 A Ay tr;,vr;s quts:lk, rcwc rsc side) f 9~5" /~ l T ~r~ y.' 9 , places, and ro;asons~.,~ List all -club 7i,- niitionsncieties you belong to or have c vrr belonged to give name.ss,, adc'.resscs,, dates, end positions h(..ld) Mise;:l.lan on_: Do you advocate or hi; you over advocated, or are you now or have you ever been a o;,mbcr of, or have you supported in political pe.rty or organi?ation which advocates t' o verthrow of our consti.tutir~nel form of Government lie the Unttcd. 'fates? _ if "Yes",expl.ain:j Have ;ou ever been arrested, indicted, or convicted for any violation of 1ai.r other then a minor traffic violation? If so, state name of court, tit;., state, country, nature of offense, and disposition of cast.: If, to your '_ no.rledge, any Govc;rnmc:nt agency has conducted an i~vcsti- g+:.tion of you, indicate below the name of that .3ec.ncy and th.-; eprmo;i- .I Pero antegr nc1? ? Nan.: Relationship Address Y (USE CTAT'P SIDE IF NFCESSARY) :IT Aro there nny unfevoroblc incid::ntn in your life not mcntioncd f~bove i.rhioh :n,-,y be discovered in subs,.qucnt investigation, whether -,fna -were U.rcctly involw:cl or not, which mi~*ht recetirc.: explanction? If o, doocribc. If not, answer "No" _ III I (.PRTIFY THAT THY FOREGOING ANSWERS ARE TRUE AND CORRECT TO THE RFf~T Cr' MY KNOWLFDGF AND BELIEF, AND I AGREY THAT ANY MISSTATEI7NT OR OMISSION AS TO A MATERIAL FACT WILL CONSTITUTE GROUNDS FOR i" ;t! TaIAT',: PISMISS"AL OR RFJFCTION OF MY APPLICATION, (U,SE'OTHER SIDE Ir N''CESSARY)