REQUEST FOR INVESTIGATION

• Document Type: SPECIALCOLLECTION
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 06578480
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 14
• Document Creation Date: March 16, 2022
• Document Release Date: July 19, 2016
• Case Number: F-2016-01921
• Publication Date: January 26, 1950

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*CENTRAL INTELLIGENCE AGENCY di
The Director
Federal Bureau of Investigation
Tenth & Pennsylvania Ave., N. W.
Washington 25, D. C.
Attention: Mr. Christopher Callan
Dear Sir:
WASHINGTON 25, D. C.
Re: Request for Investigation
26 January 195Q/
It requested that an investigation of the following named person be
Conducted n order to determine loyalty, character, discretion, trustworthiness,
financial h- its, foreign connections, and general suitability for Government
employment.
Name Reference
GIBSON, . Frank Eugene, Jr.
The above-name \person:
(C) Is an applicant for employment. .
( ) Was employed and has no access to classified information.
( ) Was employed on unclassified duties in cover status.
( ) Has been a fall employee of this Agency since
( ) Will be (Was) employed under cover designation (on ).
NO CIA interest should be indicated during the investigation.
Such portion of the completed investigation report as may
indicate CIA connection should, under no circumstances, be
disclosed to a third party without the prior approval of this
Agency. Likewise, administrative detail, in connection with
this investigation, should be so handled as to afford main-
tenance of the necessary cover.
Remarks: Name check has been initiated with your Bureau, Army, Navy, AFI,
State, CSC and HCUA and will be completed by this office.
Enc. - 1 PHS
1 C.
Form No. �
Feb 1949 38:103
t&PV 2� :
1.
(b)(3)
)1;
. �1 1/121.:
o'''' �_�266-
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AN to
,g5c
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,
11
yf
OHIKY OF INSPECTION AND SFeriPT9'V.rmart14�
Chief, Personnel Security Inximmu.
Branch
(b)(3)
(b)(6)
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PERSONAL HISTORY STATEMENT
Instructions: 1. Answer all questions completely. If question does not apply write "not applic-
able." Write "unknown" only if you do not know the answer and cannot obtain
the answer from personal records. Use the blank pages at the end of this form
for extra details on any question or questions for which you do not have suffi-
cient room.
2. Type, print or write carefully; illegible or incomplete forms will not receive con-
sideration.
HAVE YOU READ AND DO YOU 'UNDERSTAND THE INSTRUCTIONS?
Yes or No
SEC. 1. PERSONAL BACKGROUND
Pf.
ivliss-
A. FULL NAME Mr.
First ddie Last
Teglspypne:, � �
Office' MeA0A4 Yeoi arn-
Home* Ohltvi� 3:232
PRESENT ADDRESS$MC /4110�40.4 ROCa 4,10)4(aS0/.4 /i(-10/ PerA
St. & No. A City i State Country
PERMANENT ADDRESS 6�e4 C /5 ' voluhr); P,Od I/ ,)Pq 65.4 N MO/ 164
St. & No. City State Country
B. NICKNAME 0.0,9 WHAT OTHER NAMES HAVE YOU USED?
UNDER WHAT CIRCUMSTANCES HAVE YOU EVER USED THESE
NAMES?
HOW LONG? IF A LEGAL CHANGE, GIVE PARTICULARS
Where? B What A hority
C. DATE OF BIRTHLA4 q /7/1"PLACE OF BIRTH Air /11.7 ,t .pg g af-4
City State Country
D. PRESENT CITIZENSHIP as/9 BY BIRTH? 0'S BY MARRIAGE?
Country
FORM NO. 38-1
SEP 1948
BY NATURALIZATION CER lir ICATE # ISSUED
� BY
Date Court
AT
City State Country
HAVE YOU HAD A PREVIOUS NATIONALITY? A,
Yes or No Country
HELD BETWEEN WHAT DATES? � TO � ANY OTHER NATIONALITY?
GIVE PARTICULARS �
Country
HAVE YOU TAKEN STEPS TO CHANGE PRESENT CITIZENSHIP? GIVE PARTICULAR,S:
1
E.NCLOSURE i(
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E. IF BORN OUTSIDE U.S. WHEN DID YOU FIRST ARRIVE IN THIS COUNTRY?
PORT OF ENTRY? ON PASSPORT OF WHAT COUNTRY?
LAST U.S. VISA
Number Type
Place of Issue Date of Issue
SEC. 2. PHYSICAL DESCRIPTION
AGE (3/ SEX Alfil 41 HEIGHT CI /OA ilwEicarr /64
EYES st-D4,1 HAIR givaiii COMPLEXION 441*n SCARS /4/2!7/6&14
BUILD //gOle>199 OTHER DISTINGUISHING FEATURES rf)3141/911,4 Wt#61, /2114)1
tY1
SEC. 3. MARITAL STATUS
A. SINGLE
MARRIED DIVORCED WIDOWED
STATE DATE, PLACE, AND REASON FOR ALL SEPARATIONS, DIVORCES OR ANNULMENTS
B. WIFE OR HUSBAND
(IF YOU HAVE BEEN MARRIED MORE THAN ONCE �INCLUDE ANNUL-
MENTS �USE A SEPARATE SHEET FOR FORMER WIFE OR HUSBAND
,GIVIJTG DATA QUIREp pELOW FOR ALL PREVIOUS MARRIAGES.)
X/40. 1,0'67te
NAME OF SPOUSE
First
Middle
PLACE AND DATE OF MARRIAGE
HIS (OR HER) ADDRESS BEFORE MARRIAGE
St. & No.
LIVING OR DECEASED- DATE OF DECEASE
PRESENT, OR LAST, ADDRESS
St. & No.
DATE OF BIRTH PLACE OF HIRT
IF BORN OUTSIDE U.S. INDICATE DATE
CITIZENSHIP WHEN
OCCUPATION
EMPLOYER'S OR BUS
.d I
Maiden Last
City
State Country
CAUSE.
ty State Country
City State
Country
PLACE OF ENTRY
QUIRED? WHERE?
LAST EMPLOYER
City State Country
S ADDRESS
St. & No. City State
MILITARY SER FROM TO BRANCH OF S
Date Date
COUNTRY DETAILS OF OTBE
ountry
RVICE
R GOV'T. SERVICE, U.S. OR FOREIGN
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OCCUPATION
CITIZENSHIP iiCA WHEN ACQUIRED? /521,1") WHERE?
City State. Country�AZ/..i.:11 LAST EMPLOYERSPOIM'et )(e pidelkce ,2tee4/44e
EMPLOYER'S OR OWN BUSINESS ADDRESS
MILITARY SERVICE FROM
Date
� �
�
SEC. 4. CHILDREN OR DEPENDENTS (Include partial dependents)
1 NAME Ti einAl ALT: 64,1,cow � RELATIONSHIP A;?.;111/9/.. AGE 74
CITIZENSHIP 11S/9 ADDRESS
2. NAME /t,S: /t;�404e. /11 RELATIONSHIP 11//)1111e1 AGE
CITIZENSHIP ,C/49 ADDRESS
(b)(6)
rw. vity state Country
3. NAME RELATIONSHIP AGE (b)(6)
CITIZENSHIP ADDRESS
St. & No. City State Country
SEC. 5. FATHER (Give the same information for stepfather and/or guardian on a separate sheet)
FULL NAME /d12/
First / Middle Last
LIVING OR DECEASED ,16///15. DATE OF DECEASE � CAUSE
PRESENT, OR, LAST, ADDRESS .
(b)(6)
67 4. 04 4W. twicy
state Country
DATE OF BIRTH/6,. /4 /197PLACE OF BIRTH i&4'>4 C *7
City State Country
IF BORN OUTSIDE U.S. INDICATE DATE AND PLACE OF ENTRY
St. 8s No. City State Country
TO � BRANCH OF SERVICE
Date
COUNTRY DETAILS OF OTHER GOV'T SERVICE, U.S. OR FOREIGN.
SEC. 6. MOTHER (Give the same information for stepmother on a separate sheet)
FULL NAME P tri ii e �ie 5'
First /IL/pi e 1/..e 'I 3';lee.71
/ Middle iisf
j .
LIVING OR DECEASED ,A /Fill , DATE OF DECEASE � CAUSE �
/ (b)(6)
PRESENT, OR LAST, ADDRESS. I
St. & No.
City fig Country
DATE OF BIR PLACE OF BIRTH /ar/ ''' 5?Ole e ,r7/)
CITIZENSHIP Vi 19 WHEN ACQUIRED 9 $5,./2 WHERE?
City State Country
IF BORN OUTSIDE U.S. INDICATE DATE AND PLACE OF ENTRY
3
UTI
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OCCUPATION 4/019e LAST EMPLOYER M d/01kAd..14
EMPLOYER'S OR OWN BUSINESS ADDRESS
St. az No. City � State Country
MILITARY SERVICE FROM TO BRANCH OF SERVICE
COUNTRY DETAILS OF OTHER GOV'T SERVICE, U.S. OR FOREIGN.
SEC. 7. BROTHERS AND SISTERS (Including half-, step-, and adopted brothers and sisters)
Fme M edhAe
1. FULL NAME AGE
First Middle
PRESENT ADDRESS
St. 84 No. City State Country Citizenship
2. FULL NAME AGE
First Middle Last
PRESENT ADDRESS
St. & No. City State Country Citizenship
3. FULL NAME AGE
First Middle Last
PRESENT ADDRESS
St. & No. City State Country citimr/thin
4. FULL NAME AGE
First Middle Last
PRESENT ADDRESS
St. & No. City State Country Citizenship
5. FULL NAME AGE
Middle
PRESENT
DRESS
First
Last
St. dr No. City State country
Citizenship
SEC. 8. FATHER-IN-LAW
ci#/iede/46
FULL NAME
Middle
First
LIVING OR DECEASED DATE OF DECEASE CAUSE
PRESENT, OR LAST, ADDRESS
St. & No. City
DATE OF BIRTH PLACE 0 IRTH
State Country
IF BORN OUTSIDE U.S. INDICAT � ATE AND PLACE OF ENTRY
CITIZENSHIP 'WHEN ACQUIRED9 WHERE?
City State Country
OCCUPATI
LAST EMPLOYER
�
�
.411,1111iga.as,
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SEC. 9. MOTHER-IN-LAW
FULL NAME
//
/0 (7/49//ea,ae
First
Middle
LIVING OR DECEASED DATE OF DECEASE CAUSE
PRESENT, OR LAST, ADDRESS
st. & No. City State Country
DATE OF BIRTH PLACE. :ITH
IF BORN OUTSIDE U.S. INDICA DATE AND PLACE OF ENTRY
CITIZENSHIP
OCCUPATION
WHEN ACQUIRED? " WHERE?
City State Country
LAST EMPLOYER
SEC. 10. RELATIVES BY BLOOD, MARRIAGE OR ADOPTION, W1-19 rt,o4p OR,
WHO ARE NOT CITIZENS OF THE UNITED STATES: reTEX1Pallti-ivi ah/Ge
1 NAME RELATION:P AGE
CITIZENSHIP ADDRESS
. City State Country
2. NAME TIONSHIP AGE
CITIZENSHIP ADD SS
Country
3. NAME
CITIZENSHIP
St. & No.
RELATIONSHIP
City
State
AGE
ADDRESS
St. .36 No. City State Country
SEC. 11. RELATIVES BY BLOOD OR MARRIAGE IN THq, MILITAM�Ry) 7/ 7, pERvipp OF
THE U.S. OR OF A FOREIGN GOVERNMENT. yaAto.. 71` a /23eo,hice
1. NAME RELATIONSHIP AGE
CITIZENSHIP ADDRESS
St. 83 No City State
TYPE AND LOCATION OF SERVICE (IF KNOWN)
2. NAME REZONSHIP AGE
CITIZENSHIP ADDRE07
St. & No.
City State
TYPE AND LOCATION OF SERVIC (IF KNOWN)
3. NAME RELATIONSHIP AGE
CITIZENSHIP
ADDRESS
TYPE AND LOCATION OF SERVICE (IF KNOWN)
5
St. & No.
City State
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SEC. 12. EDUCATION itidoe/i)
ELEMENTARY SCHOOL -74"Al2,0915?),1
Nti
ADDRESS Afreaillif54 4'' �SA
City / State Country
DATES ATTENDED /p/-/9;4226,rA GRADUATE?
aN11,19,6,/e 0-.. it
HIGH SCHOOL 7"qe,c7",r,ipily4 ADDRESS
DATES ATTENDED /7_,Q, GRADUATE? ie'S
4,A�f if/f Ift6,-/fa ce City State Country
COLLEGE Swair /Ark' 7.4/,. ADDRESS #12f,/,) 4-4 fi ZeISA
�
DATES7f� DEGREE TA i tate llWeeAV cr. XAZie
City Dp
COLLEG
ADDRESS 0/Orgre'/A 58(
DEGREE fib211-of iiekVZ,Se)
DATES ATTENDED
SEC. 13. MILITARY, NAVAL OR OTHER GOV'T SERVICE �U.S. OR FOREIGN
A/a v .24/I've
v.,S1. A. A ivye ePe)//s---1 A (04 / dein
Country Service Rank Dates of Service
�S.
Last Station Serial No. 1 Type of Discharge
rti fe-y4J.ke, 7Z:C�
REmARKs � /hitt if eflie,//7 Wffjh r 14:� frerQewAe
SELECTIVE SERVICE BOARD NUMBER ADDRESS
eft e,o, A/
IF DEFEFIRED GIVE REASON
DICATE MEMBERSHIP IN MILITARY RESERVE ORGANIZATIONS
-7Liva f; A /1131e-re,fre - -7 it 9/7
SEC. 14. CHRONOLOGICAL HISTORY OF EMPLOYMENT FOR PAST 15 YEARS. ACCOUNT
FOR ALL PERIODS. INCLUDE CASUAL EMPLOYMENT. INCLUDE ALSO PERIODS
OF UNEMPLOYMENT. GIVE ADDRESSES AND STATE WHAT YOU DID DURING
PERIODS OF UNEMPLOYMENT. LIST LAST POSITION FIRST.
.#1 .45 fiee-Yec-, �
1. FRomur 7 1 .TO r/fr''07
2.
�
EMPLOYING FIRM OR AGENCY
ADDRESS afc5.-- 44- e J'Y
St. &
C ty
igiOrnfst)?1,e
Country
KIND OF BUSINESS li/d irP/Y*1 )//6e. NAME OF SUPERVISOR , �
me /4,4 '.eptropme d e e.oto, Pollas,a01//oetaeiti_s
(b)(6)
YOUR DUTIES
REASONS FOR LEAVING 61, 5(0.0i /h ge?Atofi /)) )/7,40
it)244,-
mommr ,20 yva TO C14'i2 /0 /9116 (7- /0/17/
A,my ta-alei-/,5�4;'saMsferi 60,(57;ri , (//d D-r-/_,�51-AW/4e47Ke Agli/AJ4 ,)
Acem2 ji,TaAey-1//spi) a ife/7 oin saiii el / / j d / '2 1 //I /*Wer>1
ONS FOR LEA ING il v* /evttse (47-arafi /./41 * "XI 14, Ao.ite 4 / 41,1* 4 . 4 ,
.e ..e.z,..,y__...y.,_._r�
EMPLOYING FIRM OR AGENCY
ADDRESS
KIND OF BUSINESS
/3/517,--4' /flea/Ale /
TIME OF JOB 709.1,64',,
YOUR DUTIES
(b)(6)
St. & o ,c/Ati
City
a/e0/40'
REASONS FOR LEAVING
NAME OF SUPERVISORS
SALARY $
4. -FRoM AJCZAhL,WleTO __Gthe2e_eas2,Z7W
EMPLOYING FIRM OR AGENCY (4-'eit /40:41 � /Velyi/ .,(/i /
MYS if
A/o/,s�
PER�
ADDRESS
St. & No.
P�g ei.s/9 �
City State
KIND OF BUSINESS PV9//2140: NAME OF SUPERVISOP
TITLE OF JOB //iX01.7e
YOUR DUTIES
REASONS FOR LEAVING
(b)(6)
SALARY $ PER �
5. FROM TO
EMPLOYING FIRM OR AGENCY (c.5)�,52/,D.
ADDRESS
St. & No. City State Country
KIND OF BUSINESS � NAME OF SUPERVISOR
TITLE OF JOB SALARY $ PER
YOUR DUTIES
REASONS FOR Lis,AVING
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SEC. 15. HAVE YOU EVER BEEN DISCHARGED OR ASKED TO RESIGN FROM ANY POSITION?
HAVE YOU LEFT A POSITION UNDER CIRCUMSTANCES WHICH YOU DESIRE TO
EXPLAIN? GIVE DETAILS:
SEC. 16. GIVE FIVE CHARACTER REFERENCES � IN nit, U.S. � WHO KNOW YOU INTI-
MATELY� (GIVE RESIDENCE AND BUSINESS ADDRESSES WHERE POSSIBLE.)
(b)(6)
e0
SEC. 17. NAMES OF FIVE PERSONS WHO KNOW YOU SOCIALLY IN THE UNITED STATES �
NOT REFERENCES, SUPERVISORS OR EMPLOYERS � (Give residence and business ad-
dresses where possible.)
v\1
Po
Street and Number
City - State
(b)(6)
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SEC. 18. GIVE THREE NEIGHBORS AT YOUR LAST NORMAL RESIDENCE IN THE U.S. � (Give
residence and business addresses where possible.)
(b)(6)
SEC. 19. FINANCIAL BACKGROUND
A. ARE YOU ENTIRELY DEPENDENT ON Y031.4 SAL,RY? IF NOT, SMITE SOURCES
OF OTHER INCOME /41//ere,7,5 ArY/n72/1/ )/f .3/ 4rr (,) .
D SS OF NKS TH I YOU HAVE
tA � 2/M3
C. HAVE YOU EVER BEEN IN, 0 PETITIONED FOR, BANKRUPTCY? A) 1,05LZX to.
GIVE PARTICULARS, INCLUDING COURT* ---
D. GIVE TlytE5 CREDIT REFVREN.. , CES IN THE U.S. is, , ,i/ /
1. NAmEfropetPard 6441 A0)5111D, ADDRESS //.1 t- (17t /NI 114/.14 A
At. as No. j 6 . State
De.
2. NAME hie 6 h 9"g C A
ADDRESS 7" )1 ..c."yg. No'
A. as Npi nit 1 ,,CI
3. NAME kidn OS ADDRESS 7-- Ysi." ...w_C ///6e, etri,/ f
St. as No. City Statehe
SEC. 20. RESIDENCES FOR THE PAST 15 YEARS �
FROM f241:1--k. TO yr/ f_27 AL?e. J>Oki, Acourtry0S4
St. No. City State
t FROIS..4-49-Y-71.0 r/f iti/x46"
St. No. City StSte (147,4
7 Country
�
FROMCAZ/71,eZA0
FROM
FROM
FROM
FROM
FROM
TO
TO
TO
TO
TO
476422, . /-10/ OS>9
St. No. City State Country
St. No. City State Country
St. No. City State Country
St. No. City State Country
St. No. City State Country
SEC. 21. RESIDENCE OR TRAVEL OUTSIDE OF THE UNITED STATES gaSz�tofrA Sy- ,t7.dAteL.�..
A. FROM411.6.30TO Ac*//1 417/41/0; 304,1PA21/1610/417 7.40A/67--
Zor Section
4/iltioe 41,..hoepediountreezezinz, Purpose
F.Rom(tmAv.eriOro .40? 7-40-re.ter..01
9,15y or Section /country. Purpose
FROM )61e.aArtelITO azigg? icit27740 /fe,e_o.4
City or Section 7 Country Purpose
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FROM TO
City or Section Country Purpose
Nan and Chapter St. & No.
PATES ,OF ';ERSHIP
11/61,s 4 /h
3 COM/Sat /id .0/f/ieli/ A4 )474 Z/12,-154
Name an Chapter ./ St. & No. City. 8ta7 Ockunts7
Dd407007.0, olpe 14..2 S-
TE� OF VE,(1ror MVP*
(.4
4./4;ra,;...;! c2/4
Name and Chapter St. & No. /City Country
PDATES OF MBNEISHIP. /9'9, ,/75 otre-i71-
t/e)e A.,04.d/Atah
5 CA tie,- Mo /75
City Country
D,TE� OF. MEMBERSHIP� /9,/, ,../sare./99
noot/l3f*--' Opyip2ian to Ay 4a. 2'
ame a � d � apter St. & No. City State
FROM TO
City or Section Country Purpose
FROM TO
City or Section
Country Puri
lose
B. LAST U.S. PASSPORT � NUMBER, DATE, AND PLACE OF ISSUE:
Aldfra iffge) 27, e .
HOW MANY OTHER U.S. PASSPORTS HAVE YOU HAD? d/PA W GIVE APPROXIMATE
DATES.
PASSPORTS OF OTHER NATIONS* 1/404
SEC. 22. CLUBS, SOCIETIES AND OTHER ORGANIZATIONS
LIST NAMES AND ADDRESSES OF ALL CLUBS, SOCIETIES, PROFESSIONAL SOCIETIES,
EMPLOYEE GROUPS, ORGANIZATIONS OF ANY KIND (INCLUDE MEMBERSHIP IN, OR SUP-
PORT OF, ANY ORGANIZATION HAVING HEADQUARTERS OR BRANCH IN A FOREIGN COUN-
TRY) ,TO CH. ,YOJI BELONG OR HAVE BELONGED:
Afediedi
rhdgam, -124/ ,k,"*�. ---Ceorpp ii,ri4040.%),4 At/Pe
Name and hapter / St. & No. / City / State CourEVA
DATES OF MEMBESHIP /93� /.7
j73'/./93c? /,2:'p,GOts *I)
Name and Chapter
0.4/fee SfiO) 11".6704.,1,/e Ar�i a,114 AF/
st. & No. / city State C�11nt7,--C/6 .
2
(b)(6)
/cy7 >p5L
6
Country
DATES OF MEMBERSHIP* / 9,/f 71-0 47,-CO>17Z-
7 Alrpes 70,2i4 A .A./9�44g /4i 4i3 p(?
Name and Chapter / St. & No. City State Country
DATES OF MEMBERSHIP. /?417 ig2r
(/ea.ze See e1/416Ae d e-)
� fairovil glee IIP
itf
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SEC. 23. GENERAL QUALIFICATIONS
A. FOREIGN LANGUAGES (STATE DEGREE OR PROFICIENCY AS "SLIGHT" "FAIR" OR
"FLUENT")
LANGUAGE/%e'1/ SPEAK SILty-1-.---. READ %.(1/yA 5/ WRITE C57i,:fi
LANGUAGE SPEAK READ WRITE
LANGUAGE SPEAK READ WRITE
B. LIST ALL SPORTS AND HOBBIES WHICH INTEREST YOU: INDICATE DEGREE OF PROFI-
CIENCY IN EACH:
--C4/m/v/h
p,ip a#7, ��0�4�� v_e.,
. .
,� ,,,, ,
C. HAVE YOU ANY QUALIFICATIONS, AS A RESULT OF TRAINING OR EXPERIENCE, WHICH
MIGHT FIT YOU FOR A PARTICULAR POSITION?
ke.10-osteel pcd(/>4,ie ea//e

10/ 6/}ivA4 csw;etia /99at if.o.." /)3 47S,0', )",/),10
() 0.c /,7eihej ice#4di71/WAr-9eeil ti,
4/v27*, /cOrwics,' I e (Y /77Ds.p//vcie) /xe,/e/e/ap/tove*ie
D. LIST BEEOW THE N OF GOVERNMENT DEPARTMENTS, AGENCIES OR OFFICES TO '
WHICH YOU HAVE APPLIED FOR EMPLOYMENT SINCE 1939:
c,/4Ail7 OS dvs-0 /./.iee/
potere..iteitte_.
� �
E. IF, TO YOUR KNOWLEDGE, ANY OF THE ABOVE HAS CONDUCTED AN INVESTIGATION OF
YOU, INDICATE BELOW THE NAME OF THAT AGENCY AND THE APPROXIMATE DATE OF
THE INVESTIGATION:
11/07/W,,
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SEC. 24. MISCELLANEOUS
A. DO YOU ADVOCATE OR HAVE YOU EVER ADVOCATED; OR ARE YOU NOW OR HAVE YOU
EVER BEEN A MEMBER OR, OR HAVE YOU SUPPORTED ANY POLITICAL.PARTY OR ORGANI-
ZATION WHICH ADVOCATES THE OVERTHROW OF OUR CONSTITUTIONAL FORM OF GOV-
ERNMENT IN THE UNITED STATES?
IF "YES", EXPLAIN*
B. DO YOU USE, OR HAVE YOU USED, INTOXICANTS? "6 5 IF SO, TO WHAT
EXTENT?
ae&is/dn aj/f evlo' 414aolizIce
C. HAVE YOU EVER BEEN ARRESTED, INDICTED OR CONVICTED FOR ANY VIOLATION OF
LAW OTHER THAN A MINOR TRAFFIC VIOLATION? IF SO, STATE NAME OF COURT,
CITY, STATE, COUNTRY, NATURE OF OFFENSE AND DISPOSITION OF CASE'
D. HAVE YOU EVER BEEN COURT-MARTIALED WHILE A MEMBER OF THE ARMED FORCES?
IF ANSWER IS "YES," GIVE DETAILS BELOW:
/fro
SEC. 25. PERSON TO BE NOTIFIED IN CASE OF EMERGENCY:
NAME /2"� /td h/e oft � 644gg:9-27 ��-57,� RELATIONSHIP
ADDRESS
St. & No. City State Counfry
SEC. 26. YOU ARE INFORMED THAT THE CORRECTNESS OF ALL STATEMENTS MADE HERE-
IN WILL BE INVESTIGATED.
,
ARE THERE ANY UNFAVORABLE INCIDENTS IN YOUR LIFE NOT MENTIONED ABOVE WHICH
MAY BE DISCOVERED IN SUBSEQUENT INVESTIGATION, WHETHER YOU WERE DIRECTLY
INVOLVED OR NOT, WHICH MIGHT REQUIRE EXPLANATION? IF SO, DESCRIBE. IF NOT, AN-
SWER "NO."
�
(b)(6)
�
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411
SEC. 27. I CERTIFY THAT THE FOREGOING ANSWERS ARE TRUE AND CORRECT TO THE
BEST OF MY KNOWLEDGE AND BELIEF, AND I AGREE THAT ANY MISSTATEMENT
OR OMISSION AS TO A MATERIAL FACT WILL CONSTITUTE GROUNDS FOR IM-
MEDIATE DISMISSAL OR REJECTION OF MY APPLICATION.
DEIGNED AT di'
and State
DATE f/r) .
(b)(6)
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Approved for Release: 2016/07/15 C06578480