(SANITIZED)

• Document Type: CREST
• Collection: General CIA Records
• Document Number (FOIA) /ESDN (CREST): CIA-RDP78-03172A000200030003-5
• Release Decision: RIPPUB
• Original Classification: S
• Document Page Count: 1
• Document Creation Date: December 22, 2016
• Document Release Date: February 21, 2012
• Sequence Number: 3
• Publication Date: October 26, 1959
• Content Type: FORM

Declassified in Part - Sanitized Copy Approved for Release 2012/02/21: CIA-RDP78-03172A000200030003-5
S-E.C?R.E.T
When filled In
WYO
Contract No.;'ti'J
RO/TO No
COIP~.4AC'!'4g=
Pur~er~s
informal
S-E-C-R.E?T
When filled in
-:
Date
Telephone
on EXT.
wired, please contact the undersigned
2 3
25X1
25X1
25X1
25X1
Declassified in Part - Sanitized Copy Approved for Release 2012/02/21 : CIA-RDP78-03172A000200030003-5