PERSONAL HISTORY STATEMENT - COLLINS, CHARLES P.

• Document Type: FOIA
• Keywords: PERSONNEL FILES
• Keywords: COLLINS CHARLES
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 0001426172
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 6
• Document Creation Date: June 22, 2015
• Document Release Date: March 20, 2008
• Case Number: F-2007-01041
• Publication Date: September 8, 1958

- --- --- ---
PEI. , JD i C SilPPLEMEHT
THIS DATE
~j ~ b) (3 )
PERSONAL HISTORY STATEMENT
U~~? ~`
'~~
This form provides the means whereby your official personnel records will be kept current. Even though it duplicates
information you have furnished previously, it will be essay fu~.,ybv to complete Sections I through VI in their
`
44
has bean a change since you entered on duty with
~
entirety, You need complete Sections VII through XI o l i'"f5tha
the organization or if yvu believe the item requires o ~%co(npf"uf erage than you have previously reporhed.
F
~; ;
I. FULL NAME (Last-First-Mi e)
0 NS C F
2. CURRENT ADDRESS (No., Street, City, Zon 'No., Street, City, Zone, State)
).~16 Linden Lane 1+16 Linden Lane
Falls Church, Virginia Falls Church, Virginia
4? HOME TELEPHONE NUMBER
5? STATE, TERRITORY, POSSESSION OR COUNTRY IN WHICH YOU NOW CLAIM RESIDENCE
US
SECTION II PERSQN TO 8E NOTIFIED IN CASE OF EMERGENCY
i. NAME (Last-k'l rst-r:4i ddle) PREFERABLY RESIDING IN U.S.
2? REL ATiON SH lP
Collins ~3rs. Charley P,
ti~'i#'e
3? HOME ADDRESS (No. Street, City, Zone, State, Covn try).
41f? Linden Lane,
Falls Church, Virginia
_
4? BUSINESS ADDRESS (,No. Stree
t, Czty, Zone, State, Country). INDICATE NAME OF FIRM OR EMPLOYER, IF RPPLICABLE
gq
N ?t7 .
5? HOME TELEPHONE NUMBER
6. BUSINESS TELEPHONE NUMBER
7? BUSINESS TELEPHONE EXTENSION
JF 4-a3$7
A~. A.
~v . ~.
8? IN CASE OF EMERGENCY, OTHER CLOSE RELATIVES (Spouse, Mother, Father) MAY AL SO 8E NOTIFIED. IF SUCH NOTIFICATION
IS NOT DESIRABLE BECAUSE OF HEALTH OR OTH ERREASON S, PLEASE SO STATE.
SECTION III MARITAL STATUS
1? CHECK (XI ONE: D SINGLE ?~ MARRIED WIDOWED SEP ARATE~ DIVORCED ANNULLED
2? FURNISH DATE, PLACE AND REASON FOR ALL SEPARATIONS, DIVORCES OR ANNULMENTS APPROVED FOR RELEASE
DATE: DEC 2007
PN.~.
SPOUSE: If you have been married more than once, including annulments, use a separate sheet. for former wife yr
husband giving data below for all previous marriages. If marriage is corttempLated, provide same data for fiance.
3? NAME (First) (Middle) (Maiden) (Last)
A? DATE OF MARRIAGE
5? PLACE OF MARRIAGE (City, State, Covn try)
C.Q. T
! ~ ~. ~4:
~~
~
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w. .4
... _. y
-
...
, ., .. ,
. ,
,
./
6? ADCRESS OF SPOUSE BEFORE MARRIAGE (No Street, City State, Country) - ~~ y
, G
.;_. _:_lr SC' : t
.... 1..:' 4...x. :i'^.. ~~
_ r ::; L? _I. ii .~
-~ ~.' `.: ~ ... i~ ~ i
~ ..:iu ~
T'v :
.
~
.
_
,
.
.
7, LIVING
8. GATE OF DEATH
9. CAUSE OF DEATH ~.~
~
-
Y E S N O
. _
y
e.1
10. CURRENT ADDRESS (Give last address; if deceased) - ~~. ~.~ ~., ~'~~p;
:17. i?f!.L rl .ice.[: .~~, ~'`r_h, ~ :~ ~.'`.~~{; ': ~e(l s"'~~_. lM?~ ~~~.,
11^rpAT.~ OF~BIRTH
12. PLACE OF BIRTH (City, State, Country) L`~ ~QC
jl ~ L: ~~ ~ .rJ Y.` L1 ~./Q ~ 1? i~ ;/3a. a/ ub it .~,.. ` ??
13? IF BORN OUTSIDE U.S.?DA T.E OF ~N TR Y'
14? PLACE GF ENTRY
?
_ `,Y
(Country)
IS? CITIZENSHIP
I6? DATE ACgUIRED ~
17? WHERE ACOUlREO (City, State, Country)
'
.a. ,_
18. OCCUPATION
t9? PRESENT EMPLGYER (Also give former employer, or if spc use is deceased or
'7i.=.~;,:~ i _ry
unemployed, last two employers)
20. EMPLOYER'S OR BUSINESSADDRESS (No. Street, City, State, Country)
SECTION Iii CONTINUED TO PAGE 2
FCRM 4LL1~ USE PREVIOUS EDITIONS.
4- 57 ~rT
SEC}~T
(fi7~en F lied In)
 S E~ET
When tiled In)
SECTION III CVNTINUED FP,OM PAGE 1
21 DATE5 OF MILITARY SERVICE OF SPOUSE (From-? and To- ) BY MONTH AND YEAR
~V . ~~ .
22? BRANCH-?OF BERVIC~IE ~
~~?t+~
23? COUNTRY WITH WHICH MILITARY SERVICE AFFILIATED
24? DETALL5 OF OTHER GOVERNMENT SERVICE, U.S. OR FOREIGN
it, ti,
SECTION IV RELATIVES BY BLOOD, MARRIAGE OR ADOPTIOk LIVING .ABROAD OR WNO ARE NOT U.S. C1T12ENS
i FULL NAME (Last-FirAg~Tst-Middle)
1\? ~?
2?
RELATIONSHIP
3?
AGE
I
4? ADDRESS OR COUNTRY IN WHICH RELATIVE RESIDES
-
5? CITIZENSHIP (Country)
6? FREQUENCY OF CONTACT
-
7? DATE OF LAST CONTACT
1 FULL NAME (Last-First-Middle)
2?
RELATIONSHIP
3?
AGE
2
4? ADDRESS OR COUNTRY IN WHICH RELATIVE RESIDES
5? CITIZENSHIP (Country)
6? FREQUENCY OF CONTACT
7? GATE OF LAST CONTACT
t? FULL NAME (Last-First-Middle)
2?
RELATIONSHIP
3?
AGE
3
4? ADDRESS OR COUNTRY IN WHICH RELATIVE RESIDES
5? C'~TIZENSHIP ICoun try)
6? FREOUENCY OF CONTACT
7? DATE OF LAST CONTACT
I? FULL NAME (Last-First-Middle)
2?
RELATIONSHIP -
3?
AGE
4
4? ADDRESS OR COUNTRY IN WHICH RELATIVE RESIDES
5? CITIZENSHIP (Country)
6? FREQUENCY OF CONTACT
7~ DATE OF LAST CONTACT
5? SPECIAL REMARKS, IF ANY, CONCERNING THESE RELATIVES ~
-
SECTION V FIkANCIAL STATUS
1. ARE YOU ENTIRELY DEPENDENT ON YOUR SALARY? YES
~.NO
2. D0 YOU HAVE ANY FINANCIAL INTEREST IN, OR OFFICIAL CONNECTIO~Q WITH, NON?U.
WITH U.S~. CORPORATIONS OR BUSINESSES HAVING SUBSTANTIAL FOREIGN -INTERESTS?
ANSWERED ?'f ES?" GIVE COMPLETE DETAILS ON A SEPARATE SHEET AND ATTACH IN A
S. CORPORATIONS OR BUSINESSES OR IN OR
~ YES ~ NO -IF YOU HAVE
SEALED ENVELOPE.
3. D0 YOU RECEIVE AN ANNUITY FROM THE UNITED STATES OR DISTRICT OF COLUMBIA-GONE N ENT UNDER ANY RETIREMENT ACT,
PENSION. OR COMPENSATION FOR MILITARY OR NAVAL SERVICE? ~ YES [h NO
r
4. IF YOU HAVE ANSWERED 'AYES" TO QUESTION 3 ABbVE, GIVE COMPLETE DETAILS.
S. WITH OUT REFERENCE TO YOUR SALARY, STATE OTHER SOU-RCES OF RECURRENT INCOME
stocks, ~?r~:~:~s, i4ea1 Estate
NOT INDICATED BY PRECEDING ITEMS,
 SECTION V CONTINUED FROM PA E,~'2
4?
HAVE.YOU~EVER BEEN IN, OR PETITIONED FOR, BANKRUPTCY? YES No
5.
IF YOUR ANSWER IS "YES" TO THE A80VE QUESTION, GIVE PARTICULARS, INC~L ING`COURT AND DATE(S)
6.
00 YOU RECEIVE AN ANNUITY FROM THE UNITED STATES OR DISTRICT OF COLUMBIA GOV RNMENT UNDER ANY RETIREMENT ACT,
PENSION, OR COMPENSATION FOR MILITARY OR NAVAL SERVICE? O yES Na
7?
IF YOUR ANSWER IS ~~YES~~ TO THE ABOVE QUESTION. GIVE COMPLE T.E DETAILS
8?
DO YOU HAVE ANY FINANCIAL INTEREST IN. OR OFFICIAL CONNECTION WITH, NON?U:S. CORPORATIONS ORSINESSES OR IN OR
WITH U.S. CORPORATIONS OR BUSINESSES HAVING SUBSTANTIAL FOREIGN INTERESTS? IF YOU HAVE
a YES NO
ANSWERED "YES". GIVE COMPLETE DETAILS ON A SEPARATE SHEET AND ATTACH IN A SEALED ENVELOPE.
SECTION VI CITIZENSHIP
i?
PRESEN TTCITIZENSHIP (Country)
`J~S~
2? CITIZE NSH IP AC OUIRED BY CHECK (X) ONE:
~81RTH MARRIAGE aOTHER (Sp eci t'y ):
3?
HAVE VOU TAKEN STEPS TO CHANGE YOUR
PRESENT CITIZEN SHIP? ~yES ? No
4? GIVE PARTICULARS
5?
IF YOU HAVE APPLIED FOR U.S. CITIZENSHIP, INDICATE PRESENT STATUS OF YOUR APPLICATION (First papers,-etc..)
SECTION VII EDUCATION
t. CHECK (X) HIGHEST LEVEL OF EDUCATION ATTAINED
LESS THAN HIGH SCHOOL GRADUATE
OVER TWO YEAR SOF COLLEGE - NO DEGREE
HIGH SCHOOL GRADUATE
BACHELO R?S DEGREE
TRADE, OUSINE55, OR COMMERCIAL SCHOOL GRADUATE
GRADUATE STUDY LEADING TO HIGHER DEGREE
TWO YEARS COLLEGE OR LE55
MASTERS DEGREE DO.C TORS DEGREE
2. COLLEGE OR UNIVERSITY STUDY
NAME AND LOCATION OF COLLEGE OR~
E
TY
SUBJECT
DATES ATTENDED
DEGREE
DATE
SEM~OTR.
UNIV
RSI
`
MAJOR
MINOR
fROM
TO
RECD
RECD
HOURS
SPECIFY
2
3. TR AOE, COMMERCIAL AND SPECIALIZED SCHOOLS
DATES ATTENDED
TOTAL
NAME OF SCHOOL
STUDY OR SPECIALIZATION
FROM
To
MON TH5
4?
MILITARY TRAINING (Full time duty in specialized schools such as Ordnance, Intelligence, Co mmvnication
s, etc.)
NAME OF SCHOOL
DY OR
ST
P
DATES ATTENDED
TOTAL
U
S
ECIALIZATION
FROM
70
MONTHS
5.
OTHER EDUCATIONAL TRAINING NOT INDICATED ABOVE
SE~ET
(When tiled In)
 SECy~'ET
SECTION Ylil FOREIGN LANGUAGE ABILITIES
COMPETENCE - IN ORDER LISTED
HOW AC
QUIRED
LANGUAGE
EQUIVALENT
FLUENT
ADEQUATE
ADEQUATE
Lisf below each !an ua a in
which you possess any degree
of competence. Indicate your
TO
NATIVE
FLUENCY
BUT
OBVIOUSLY
FOREIGN
FOR
RESEARCH
FOR
TRAVEL
LIMITED
KNOWLEDG
NATOIVE
COUNTRY
pROLONGE
RESIDENCE
CONTACT
(WITH
PARENTS
ACADEMIC
STUDY
(ALL
proficiency to read, write or
s
lacin
a check
eak b
in
X
R READ W WRITE S SPEAK
ETC.)
LEVELS{
p
y p
g
(
)
the appropriate boxes)
R
W
S
R
W
S
R
W
S
R
W
S
R
W
S
2. IF YOU HAVE CHECKED ~~ACADEMIC STUDY ~~ UNDER ~~H OW ACQUIRED~~? INDICATE LENGTH AND INTENSIVENESS OF STUDY
3? DESCRIBE YOUR ABILITY TO DO SPECIALIZED LANGUAGE WORK INVOLVING VOCABULARIES AND TERMINOLOGY. ON THE SCIENTIFIC,
ENGINEERING, TELECOMMUNICATIONS, MILITARY OR ANY OTHER SPECIALIZED FIELD
SECTION IX GEOGRAPHIC AREA KNOWLEDGE
1? LIST BELOW ANY FOREIGN REGIONS OR COUNTRIES OF WHICH YOU HAVE KNOWLEDGE GAfNED AS A RESULT OF RESIDENCE, TRAVEL,
STUDY OR WORK ASSIGNMENT. UNDER COLUMN ~~TYPE OF SPECIALIZED KNOWLEDGE~~? INDICATE TYPE OF KNOWL EDGE,SUCH AS
RRA N COAST R RS T L T ES RAILROADS I D STR ES POLITICAL PARTIES ETC.
DATES OF
KNOWLEDGE ACQUIRED BY
NAME OF REGION OR COUNTRY
TYPE OF SPECIALIZED KNOWLEDGE
RESIDENCE.
TRAVEL, ETC.
RESI?
DEN CE
TRAVEL
~
STUDY
- WORK
ASST GN?
MENT
2. INDICATE THE PURPOSE OF VISIT, RESIDENCE OR TRAVEL FOR EACH OF THE REGIONS OR COUNTRIES LISTED ABOVE
SECTION X TYPING AND STENOGRAPHIC SKILLS
1? TYPING (W?P.M.)
p. SHORTHAND(W.P.M.)
3? SHORTHAND SYSTEM USED CHECK (X) APPROPRIATE ITEM
GREGG SP EEDWR ITING STENOTYPE OTHER (Specify);
4. INDICATE OTHER BUSINESS MACHINES WITH WHICH YOU HAVE HAD OPERATING EXP-ERIENCE OR TRAINING (Comptometer, Mimeo-
graph, Card Pvnch, efc.)
SECTION XI SPECIAL QUALIFICATIONS
1. LIST ALL HOBBIES AND SPORTS IN WHICH YOU ARE ACTIVE OR HAVE ACTIVELY PARTICIPATED. INDICATE YOUR PROFICIENCY
IN EACH
2? INDICATE ANY SPECIAL QUALIFICATIONS, RESULTING FROM EXPERIENCE OR TRAINING, WHICH MIGHT FIT YOU FOR A PARTICULAR
POSITION OR TYPE OF WORK
3? EXCLUDING EQUIPMENT N07ED IN SECTION X, LIST ANY SPECIAL SKILLS YOU POSSESS RELATING TO OTHER EQUIPMENT OR MA?
CHINES SUCH AS OPERATION OF SHORTWAVE RADIO, MULTILtTH, TURRET LATHE, SCIENTIFIC AND PROFESSIONAL DEVICES, ETC.
4? IF YOU ARE A LICENSED OR CERTIFIED MEMBER OF ANY TRADE OR PROFESSION (Pilot, Electrician, Radio Operator, Teacher,
Lawyer, CPA, Medical Technician, arc.), INDICATE THE KIND OF LICENSE OR CERTIFICATE, NAME OF ISSUINGSTATE, AND
REGISTRY NUMBER, IF KNOWN.
5? FIRST LICENSE OR CERTIFICATE (Year of issue)
6. LATEST LICENSE OR CERTIFICATE(Year of issue) ,
 SECTION XI CONTINUEC FROM PAGE 4
7? LIST ANY SIGNIFICANT PUBLISHED MA7ERI ALS OF WHICH YOU ARE THE AUTHOR (Do not submit copies vntess requested).
INDICATE TITLE. PUBLICATIONDATE, AND TYPE OF WRITING (Non-fiction, scientific articles, general interest sub-
jects, novels, short stories, etc.) ?
8? INDICATE ANY DEVICES WHICH YOU HAVE INVENTED AND STATE WHETHER OR IJOT THEY ARE PATENTED
9? LIST ANY PUBLIC SPEAKING AND PUBLIC RELATIONS EXPERIENCE
10. LIST ANY PROFESSIONAL, ACADEMIC OR HONORARY ASSOCIATIONS OR SOCIETI ES IN WHICH YOU ARE NOW 0'R WERE FORMERLY A
MEMBER. LIST ACADEMIC HONORS YOU HAVE RECEIVED. -
SECTICN XII ORGANIZATION WORK EXPERIENCE - SINCE LAST COMPLETION OF A PERSONNEL QUALIFICATIONS QUESTIONNAIR?
f? INCLUSIVE DATES (From- and To-)
+ 2? GRADE
3. OFFICE/DIVISION/BRANCH OF ASSIGNMENT
4? N0. OF EMPLOYEES UNDER YOUR DIRECT
5. OFFIC I~AL POSITION TITLE
1
SUPERVISION
6? DESCRIP TIOM OF DUTIES
1. INCLUSIVE DATES (From- and To-)
I2? GRADE
3, OFFICE/DIVISION/BRANCH OF ASST GNMENT
4? N0. OF EMPLOYEES UNDER YOUR DIRECT
5. OFFICIAL POSITION TITLE
SUPERVISION -
'
2
6? DESCRIPTION OF DUTIES
f. INCLUSIVE DATES (From- and To-)
p. GRADE
3. OFFICE/DIVISION/BRANCH OF ASSIGNMENT
4? N0. OF EMPLOYEES UNDER YOUR DIRECT
5. OFFICIAL POSITION TITLE
SUPERVISION
3
6? DESCRIPTION OF DUTIES
1. INCLUSIVE DATES (From- and To-)
2? GRADE
3. OFFICE/DIVISION/BRANCH OF ASSIGNMENT
4? N0. OF EMPLOYEES UNDER YOUR DIRECT
5. OFFICIAL POSITION TITLE
SUPERVISION
4
6? DESCRIPTION OF DUTIES
~: w=
i? INCLUSIVE DATES (From- and To-)
2? GRADE
3. OFFICE/DIVISION/BRANCH OF ASSIGNMENT
1
p.. fs5 . -~ ~. g't,
4? NO. OF EMPLOYEES UNDER YOUR DIRECT
5. OFFICIAL POSITION TITLE
5
SUPERVISION
6? DESCRIPTION OF DUTIES
(Use addi bona! pages i f required)
SEC T
(iVhen Ited'In)
 SECTION, XIII
AN OTHER DEP
CHILDREN ENDENTS
1? NUMBER OF CHILDREN
and adopted childr
UNDER 21 YEARS OF
SUPPORTING.
(InclvdinQ stepchildren
en)
WHO ARE UNMARRIED,
AGE, AND ARE NOT SELF-
D
2? NUMBER OF OTHER E (~ 1~~$o~ise,
parents, stepparrnfs, sister, LN1.~~ j,
WHO DEPEND ON YOU FOR AT LEAST 50`r OF
THEIR SUPPORT;~OR.~CH ILDREN OVER 21 YEARS
E P
3. PROVIDE THE FOLLOWING INFORMATION FOR ALL CHILDREN AND DEPENDENTS
SEX
ADDRESS
NAME
RELATIONSHIP
YEAR OF BIRTH
M
F
CITIZEN SH IP~
MA
,l RUOM
ADDITIONAL COMMENT AND/OR CONTINUATION OF PRECEDING ITEMS
19111. - 192 118 N, Gre~r~+ra~r Blvd.. Falls C~arch# V3rg.a
1952 - 195ls 1116 ~lnden ~n~ -Falls Churc~i, ~'ix~ginia
195. - 1956 Fraa~c~urt, ~erma.~,y
195b - Preset x.16 T~Lnden Ir~ze Fall$ C&archs girgir3ia~ .
i
DATE COMPLETED
- ~
SIGNATURE 0 CEEa
~
SEC T
(When Iled In)