APPLICATION FOR ACCESS TO NATIONAL SECURITY INFORMATION AND MATERIAL FOR HISTORICAL RESEARCH PURPOSES

• Document Type: CREST
• Collection: General CIA Records
• Document Number (FOIA) /ESDN (CREST): CIA-RDP77-00389R000100220005-7
• Release Decision: RIFPUB
• Original Classification: K
• Document Page Count: 2
• Document Creation Date: December 12, 2016
• Document Release Date: October 25, 2001
• Sequence Number: 5
• Content Type: FORM

APP) ATION FOR ACCESS TO I"-TIONAL SECURITY INFORMATION
AND
MAT~~ e~ ~ t'1~~2 T1y PC1ApRDI 7-00:
1 Ti Agency)
Permission is requested to examine official classified files for use in unofficial research as provided for by Executive Order 11652
(Sec. 12)--and subject to procedures established by the agency which originated the records. s` CITIZEN OF
3. APPLICANT ast name, first Warne, rmdd a name - -
H U.S.
OTHER (Specify)
10. NAME AND ADDRESS OF EMPLOYER OR INSTITUTION
It. OTHER INSTITUTION. ORGANIZATION. OR AGENCY WITH WHICH ASSOCIATED FOR PURPOSES OF THIS RESEARCH. INDICATE IN WHAT CAPACITY.
2. SUBJECT. SCOPE. AND PURPOSE OF RESEARCH. (Explain in detail. Use additional sheet if necessary.)
14. LIST NAMES AND ADDRESSES OF ASSISTANTS (RESEARCHERS AND TYPISTS) WHO WILL PARTICIPATE IN THE PROJECT 'AND WHO WILL REQUIRE A
SECURITY CLEARANCE.
$ I S PUBLICATION CONTEMPLATED? ,__ YES INO
17. NAME OF PUBLICATION
16. TYPE OF PUBLICATION
LEI BOOK NEWSPAPER D MAGAZINE
Q OTHER (Specify)
Conditions governing,occ~ess to official classified records for historical research purposes which are listed on the reverse side must
be read and signed b rEOPtR>~5 e2O 2MI41(z A-R4 7 zOO3&9ROO1O I`OO2 U5o7rds will be required for
this research topic.
(PROPOSED STANDARD FORM)
 CONDITIO_ GOVERNING ACCESS TO NATIONAL SF`IRITY
ApproV 56~ AtW AIQ" RDAL MA+RM Mgl9 0005-7
1. I will abide by the regulations for safeguarding classified information issued by the Federal
agency to which this application is being made or regulations which otherwise have been made
applicable to the conduct of my historical research by the aforesaid agency.
2. I understand that any classified information which I receive affects the national defense or
foreign relations of the United States (collectively termed "national security").
3. I understand that the agency to which this application is directed can only give permission to
'see documents which that agency originated.
4. 1 agree to 'safeguard the classified information or material, to which .1 gain possession or
knowledge as a result of my access to files of any Federal agency, in a manner consistent with
Executive Order 11652 and the National Security Directive of May 17, 1972.
5. 1 agree not to reveal to any person or agency any classified information obtained as a result
of this access except as specifically authorized in writing by the Federal agency which approved
my access, and I further agree that I shall not use the information for purposes other than that set
forth in my application.
6. I agree to submit my research notes for security review, to determine if classified information
is contained therein, prior to their removal from the specific area assigned me for research. I fur-
ther agree to submit my manuscript for a similar review, if required, prior to its publication or pres-
entation. In each of these reviews, I agree to abide by the decisions to safeguard official informa-
tion in the interests of the security of the United States, including the retention or deletion of any
classified parts of such notes and manuscript whenever the Federal agency concerned deems such
retention or deletion necessary.
7. I understand that failure to abide my conditions in this 'statement will constitute sufficient
cause for canceling my access to classified information and for denying me any future access, and
may subject me to criminal provisions of Federal Law as referred to in 8, below.
8. I am aware that the provisions of Title 18, U.S. Code, "Crimes and Criminal Procedures" and
of the "Internal Security Act of 1950", as amended (Title 50, U.S. Code), prescribe, under certain
circumstances, criminal penalties for the unauthorized disclosure of information respecting the
national defense and for loss, destruction or compromise of such information.
THIS STATEMENT IS MADE TO THE UNITED'STATES GOVERNMENT TO ENABLE IT TO EX-
ERCISE ITS RESPONSIBILITY FOR THE PROTECTION OF INFORMATION AFFECTING THE
NATIONAL'SECURITY. I UNDERSTAND THAT ANY MATERIAL FALSE -STATEMENT WHICH
I MAKE KNOWINGLY AND WILFULLY WILL SUBJECT ME TO THE PENALTIES OF TITLE 18,
U.S. CODE, SECTION 1001.
Approved For Release 2002/01/10 : CIA-RDP77-00
I