PERSONAL HISTORY STATEMENT

• Document Type: FOIA
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 06675436
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 13
• Document Creation Date: March 9, 2023
• Document Release Date: December 16, 2021
• Case Number: F-2021-02476

�
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ALL FBI INFORMATION DONTAINE
HEREIN IS UNCLASSIFIED
DATE 11-10-2(11e BY 336355T41 ADC
PERSONAL HISTORY STATEMENT
. s3er- ice Cenre
Jam mati,on
on
Instructions: 1: Answer all questions completely. If question does not apply*rite "not applic-
able." Write "urilmown".only if you do not know the answer lind 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? Y= s
Yes or No
SEC. 1. PERSONAL" BACKGROUND
Ms nI
A. FULL NAME Mr
PH
Telephone:
/ � Mee. Al a.. 3 3 3
1_4(4.1-5(z.e f
igisteLR;
PRESENT ADDRESS
Fir
Middle
Last
Home* All Y30
(b)(6)
dr No
City
State
country
(b)(6)
PERMANENT ADDRESS
Bt. dr No.
City
State
county
NICKNAME ph I WHAT OTHER NAMES HAVE YOU USED?
A/6
UNDER WHAT CIRCUMSTANCES HAVE YOU EVES USED THESE
NAMES?
HOW LONG? IF A LEGAL CHANGE, GIVE PARTICULARS �
M/mm? BylnattliumftY
p /-1 C. DATE OF BIRTH qtr-.3.-t�flz3PLACE (*MIRTH De vo r1/4. cbt bl 4 a� Si 4
City State Country
D. . PRESENI!bitIZENSHIP----IRTH? Yc-s� BY MARRIAGE?
Country
BY NATURALIZATION CERTIFICATE # ISSUED BY �
Data Court
FORM NO.
38.1
SEP 1948
AT
City State Country
HAVE YOU HAD A PREVIOUS NATIONALITY?
ivo
Yes or No Country
HELD BETVVEEN WHAT DATES? � TO � ANY OTHER NATIONALITY?
Country
GIVE PARTICULARS
HAVE YOU TAKEN STEPS TO CHANGE PRESENT CITIZENSHIP? 46. GIVE PARTICULARS:
1
ENCLOSUIIL " 7 (FDPS 7)
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2
E. IF BORN OUTSIDE U.S. WHEN DID YOU FIRST ARRIVE IN THIS COUNTRY?
POET OF .ENTRY? � ON PASSPORT OF WHAT COUNTRY?
LAST 'US: VISA �
Number Type
Place of Issue Date of Issue
SEC. 2 PHYSICAL DESCRIPTION
AGE 2. 7 sg x /1174 k- HEIGHT 5 '1 N WEIGHT
EYES /442*, "CI HAIR e "'O&M compLExica r4.1 sCARs /071
Ennui Aircrage OTHER DISTINGUISHING FEATURES
1
SEC. 3. MARITAL STATUS
A. SINGLE MARRIED DIVORCED WIDOWED
STATE DATE, PLACE, AND REASON FOR ALL SEPARATIONS, DIVORCES OR ANNULMENTS
v�e
(IF YOU HAVE BEEN MARRIED MORE THAN ONCE INCLUDE ANNUL-
S. WIFE OR HUSBAND MEETS --�� USE A SEPARATE SHEET FOR FORMER WIFE OR HUSBAND
�nrsenrretrro wireADTA(WCI 1
NAME OF SPOUSE
First athicSe mamma
PLACE AND DATE OF MARRIAGE LJof1,frzcjto4 P�1 2-r, /5
MEM HER) ADDRESS BEFORE MARRIAGE
St. & No. CUP State Country
LIVING OR DECEASED 1-i i n 1 DATE OF DECEASE CAUSE
PRESENT, OR LAST, ADDRESS
St. & No.
DATE OF BIRTH Dec.,31 n IACE OF BIRTH
City
WS .
City
State
-D � C
State
Country
ti .5- 4
IF BORN OUTSIDE U.S. INDICATE DATE AND PLACE OP: ENTRY
CITIZENSHIP Lif � 5 - WHEN ACQUIRED? 8 A WHERE?
City State Country
OCCUPATION /.4-1, (4 1 C 1.4"//1 '4' LAST EMPLOYER
EMPLOYER'S OR BUSINESS ADDRESS
St. & No. City State Country
MILITARY SERVICE FROM
Date
Date
BRANCH OF SERVICE "
COUNTRY DETAILS OF OTHER GOV'T. SERVICE, U.S. OR FOREIGN
FOPS 8
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SEC. 4. CHILDREN OR DEPENDENTS (Include partial dependents) AI 007 e_.
1.
2
3
NAME
RELATIONSHIP
AGE
CITIZENSHIP
ADDRESS
NAME
St. & No. City
Stute
Country
AGE
RELATIONSHIP
ADDRESS
CITIZENSHIP
NAME
St. & No. ' City.
RELATIONSHIP
State
Country
AGE
ADDRESS
CITIZENSHIP
St. & No. City
State
Country
,�������=,
SEC. 5. FATHER (Give the same ipformation for stepfather and/or ardian on a ara s � ee
FULL NAME.
LIVING OR DECEASED I I/
P
PRESENT, OR, LAST, ADDRESS
DATE OF BIRTH- 6/ in PLACE OF BIRTH
VI i14./V0 4.
Country
Chna.., �1SQ..
City State
Country
IF BORN OUTSIDE U.S. INDICATE DATE AND PLACE OF ENTRY
CITIZENSHIP U S WHEN ACQUIRED? I rill WHERE? -----
Clty State . Country
OCCUPATION creGE wi Atra LrefsT =puma ri-c PLC h.
C.Ecirity,
EMPLOYER'S OR OWN BUSINFASS ADDRESS /706 (1-lai h ar S Centel .1 U. 5: 4--
, St. & No. City State Country
MILITARY SERVICE FROM i 9 4 6 TO 1144 BRANCH or SERVICE a-c.:,
Date Date a r-i --
n. 1110-Art v ,
COUNTRY II " 5 DETAILS OF OTHER GOV'T SERVICE, U.S. OR FOREIGN.
SEC. 6. MOTHER (Give
FULL NAME
LIVING OR DECEASED Li u Ih5.. DATE OF DECEASE
PRESENT, OR LAST, ADDRESS
t,ountry
DATE OF BIRTH 6 I, /I � I � 9'00 PLACE OF BIRTH Pao (f.
CITIZENSHIP U C � WHEN ACQUIRED? 4171114 WHERE?
City State Country
IF BORN OUTSIDE U.S. INDICATE DATE AND PLACE OF ENTRY
3
FDPS 9
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ocCutiaTiori';h0 se' Os �LE,LA/3T EMPLOYER :,:,--,-r---
EMPLititERPE3 OR OWE BUSINESS ADi;RESS
at. & No. CRY State Country
. �
11/14ITAitt stavics FROM TO BRANCH OF SERVICE
COUNTRY.' DETAILS OF OTHER, GOVT SERVICE, U.S. OR 'FOREIGN.
and sisters)
(b)(6)
AGE
(b)(6)
unistenship n (b)(6)
J.AGE i.r � )
(b)(6)
3. FULL NAME AGE
First
Middle
Last
� PRESENT ADDRESS
St. & No. City State Country Citizenship
4. FULL NAME AGE
First Middle Last
PRESENT ADORES
St. & No. City State Country Citizenship
5. FULL NAME AGE
First Middle Last
eRESENT ADDRESS
St. & No. City State Country Citizenship
SEC. 8. FATHER-IN-LAW
FULL NAME
rust
LIVING OR DECEASED t 1114 5
PRESENT, OR LAST, ADDRESS
Middle
DATE OF DECEASE
Last
CAUSE
o
pri/177 ." �
DATE OF BIRTH PLACE OF BIRTH
Lacy State
Country
/Vett] , c4111.
-
IF
IF BORN OUTSIDE U.S. INDICATE DATE AND PLACE OF ENTRY �
CITIZENSHIP 14" 5. WHEN ACQUIRED? 12/47/1 WHERE?
City State Country
OCCUPATION .13 4 n A'e r- LAST EMPLOYER -Tsfrl Trefrt a.77;o L &Lira,/
'Co r eCc 5 -re- CA 47 7-1 o4-; 41,1
De yelp,41etiT
FDPS 10
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SEC. 9.- MOTHER-IN-LAW
FULL NAME �
First AUCIQUI
LIVING OR DECEASED )4 VIM? DATE OF DECEASE CAUSE
PRESENT, OR LAST,. ADDRESS
,adSt. & No. city State Country
DATE OF BERTHSCP g 4/ YPILA6CE OF BIRTH CAT-4 514, 415.76k
IF BORN OUTSIDE U.S. INDICATE DATE AND PLACE OF ENTRY
'CITIZENSHIP U� 5. WHEN ACQUIRED? IS IrTtl WHERE?
OCCUPATION _BO� 5ewil'e LAST EMPLOYER
City State Country
SEC. 10. RELATIVES BY BLOOD, MARRIAGE OR ADOPTION, WHO EITHER LIVE ABROAD OR
WHO ARE NOT CITIZENS OF THE UNITED STATES:
1.
2.
3.
RELATIONSHIP
AGE
NAME
CITIZENSHIP
ADDRESS
NAME
& No.
RELATIONSHIP
City
State
Country
AGE
CITIZENSHIP
ADDRESS
NAME
& No.
RELATIONSHIP
City
State
Country
AGE
CITIZENSHIP
ADDRESS
St. & No.
City
State
Country
SEC. 11. RELATIVES BY BLOOD OR MARRIAGE IN THE MILITARY OR CIVIL SERVICE OF
THE U s OR OF A FOREIGN GOVERNMENT.
RELATIoNsiirp1a-74e r- jadiGE 5-3
1. NAME _
CITIZENSHIP 1 -5 ADDRESS
101:04216.
St. & No. City State
YPE AND LOCATION OF SERVICE (IF KNOWN) ado, pilerp.1.7/OpietZ 824k
Fcr r7ecoralrell c T.c et 7) ceps_ (c..e 044Ger
NAME RELATIONSHIP AGE
(b)(6)
(b)(6)
CITIZENSHIP ADDRESS
St. & No. City State
TYPE AND LOCATION OF SERVICE (IF KNOWN)
3. NAME RELATIONSHIP AGE
CITIZENSHIP ADDRESS
St. & No. City State
TYPE AND LOCATION OF SERVICE (IF KNOWN) .._
5
FOPS 11
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SEC. 12. EDUCATION �
ELEMENTARY SCHOOL '7c40 r kb 9 ii ADDRESS CU4yn e� "0114 ; II' 5�1
Ci Country
DATES ATTENDED 454 / - / 9 3a GRADUATE? 474ePta
HIGH SCHOOL Fe/SC.04pol. ilea Je-lbly ADDREss Ot/Crbree,k, 64144 . O. S14.
City State Country
MDATES ATTENDED /131� 1.1 ild GRADUATE? yes
COLLEGE V 41-e Unsvers- tri ADDRESS P.M, RaUe� i ann.. a ' s- ti,
City Country
DATES ATTENDED / / # 0 - / 9 i13 DEGREE e6:177 � ,
COLLEGE ADDRESS
City State Country
DATES ATTENDED DEGREE
SEC. 13. MILITARY, NAVAL OR OTHER GOV'T SEKvICE--TJ.S. OR FOREIGN
WPO
0- c � U.S. (Marine darpf 15r1-7-. 3-41Y MIS -m4rr-4-0(
_rt. Country Service Rank Dates of Service
5.- acts c 7)-c1pi7i el (.40-rn . 0 3 tcts-o ec te05-ed riong a-c-ive ciaiii
Last Station Serial No. . Type of Discharge
REMARKS' p_re 3- a/4T 5 1r4 t- - 7 - a ...r 7 or 6 hi- lei te ex' neSe r if e - 0 5 fril - C �
SELECTIVE SERVICE BOARD NUMBER q S.- ADDRESS Life 57- Clie57Q I-- P
)
IF DEFERRED GIVE REASON 444e141 he r di 4 5. A4 c . if cs e r v e_
INDICATE MEMBERSHIP IN MILITARY RESERVE ORGANIZATIONS Vidu ii-Te -e r-
g es e r v co 0. S I`I , C . ,
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.
FROM '1)01/. /5 3/ 7 TO ?r-c5--e PO-
EMPLOYING FIRM OR AGENCY -Th -e tkiaii STre-e / joor pig
-y u Sr -77319.es Plc .
ADDRESS 44/ aroa j. g etAJ Yu- A/ .s
St. 8. No. City -State Country
KIND OF BUSINESS Ale ws6c)ae) r- NAME OF SUPERVISOR to"' Palle p--
TITLE OF JOB etur re SP6P1 It LI 7- SALARY $
YOUR DUTIES .47eep.9/7h9 -1- (i-) 17-0 h 9 1-06 te- Nettes am tt.
REASONS FOR LEAVING 7[5 V e rn C lir Se r Lf/ c e
1.
2. FROM MQy 1711 TO NO V "Y7
EMPLOYING FIRM OR AGENCY Pre5 5 a, SG C CU I 6 tor CoP2
FDPS 12
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ADDRESS
11/.4A. � a 5..
St. &. No. City Btate COuntrf�
RINI) OF BUSINESS A4 L&5 4f..1./C.6.9NADII2 OF SUPERVISOR .116,...)zrei )ramy
TITLE OF JOB
YOUR DUTIES
REASONS FOR LEAVING
Ed/ 7- n
SALARY t
110
PER tAre-a-te.
nterr-4 _ tat,2*.e.
eft�e_e_e_Ar
3. FROM TO --Ola1.--M-42�.
EMPLOYING FIRM OR AGENCY' A..e2r4
ADDRESS 5171. 1-1157 IAL-.0 4.
St. & No. City
KIND OF BUSINESS 14- /-e (-14 ahinfrt NAME OF SUPERVISOR Po Lc-) ia 141
TITLE OF JOB 4# 1.77 -e SALARY $ 12 PER 14"4-44.
YOUR DUTIES li--4-410-4-4-L-41 64-4- elter 0.1-tresute4A-a
REASONS FOR LEAVING -
C-
State Country
4. FROM -.141.28.a. 114t TO
OR AANa J.14;A4.CY
EMPLOYING FIRM
ADDIERSE-
St. & No. City State Country
KIND OF BUSINESS 1,4-a-refly4X NAME OF SUPERVISOR
TITLE OF JOB
SALARY $ PER
YOUR DUTIES
REASONS FOR LEAVING
5. FRONLYZA iy 19 / 3 TO -ta-ct /q0Z
EMPLOYING FIRM OR AGENCY 71 5: /41eZ r/A/ C
ADS- /24-.
St. & No. City
KIND OF BUSINESS
TITLE OF JOB
1.
YOUR DUT.ES
REASONS FOR LhAVING
Corips
State Country
NAME OF SUPERVISOR
SALARY $ PER
7
FDPS 13
J7?
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8
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 CHARM, i hit REFERENCES � IN THE U.S. � WHO KNOW YOU INTI-
MATELY � (GIVE RESIDENCE AND BUSINESS ADDRESSES WHERE POSSIBLE.)
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.)
FDPS 14
(b)(6)
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 YOUR SALARY?
OF OTHER INCOME
B. NAMES AND ADDRESSES OF BANKS WITH_ DIKICH ,HAVE ACCO
C. HAVE YOU EVER BEEN IN, OR PLITTIONED FOR, BANKRUPTCY? -71 C.
GIVE PARTICULARS, INCLUDING COURT.
IF NOT, STATE SOURCES
D. GIVE TERikaAFS C IdeE'Lei..A_.2.(1DREFERENCES �IN THE U.S.,
1. NAME DRESSi q" `3( 241a44' (b)(6)
dt NO.
toty
SEC. 20. RESIDENCES FOR THE PAST 15 YEARS
4J 'O FROM 51-1/4150TO 662124,47-
FROMtielp720/To /-6U.4-/ ?SW
FROM JCIAAL
FRoma69, /4-4'gTo aru.; xxtr
pRomj-11--/17-3 To CAtil/ gfid�
FROM TO
FROM TO
FROM TO
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
A. FROMie I, ifs-TO go-A/S-14:re et-4-1--Pa
City or Section Country Purpose
FROM TO
City or Section Country Purpose
FROM TO
City or Section
9
Country Purpose
FDPS 15
(b)(6)
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10
FROM
FROM
FROM
City or Section
Country Purpose
City or Section
Country Purpose
City or Section Country
B. LAST U.S. PASSPORT � NUMBER, DATE, AND PLACE OF ISSUE' 114"-ralfrfree2f- �
HOW MANY OTHER U.S. PASSPORTS HAVE YOU HAD? GIVE APPROXIMATE
DATES:
PASSPORTS OF OTHER NATIONS'
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 WHICH YOU BELON OR HAVE BELONGED:
1 Itair24-^a-40
Name and Chapter
DATES OF MEMBERSHIP: (77-4-1-cd. I_Yfi. -75
2 ait.L.0 76,14J;� 711441-141244. 657'r,v1-
DATES OF MEMBERSHIP' 5 9/ CI"
Name and Chapter . & No. &m&e Country
3.
4
5
7
)L0 Chii217-d-4144c. 71 C. 24 Y.
St. ,di No. C14- State
Country
Name and Chapter
St. & No.
City
State
Country
DATES OF MEMBERSHIP'
Name and Chapter
8t. & No. City
State Country
DATES OF MEMB. TritSHIP'
Name and Chapter
St. & No. City
State Country
DATES OF MEMBERSHIP -
Name and Chapter
St. & No. City
State Country
DATES OF MEMBERSHIP.
' Name and Chapter at, & No.
City
State Country
DATES OF MCEIVIBERSHIP �
FDPS 16
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SEC. 23. GENERAL QUALIFICATIONS
A. FOREIGN LANGUAGES (STATE DEGREE OR PROFICIENCY AS "SLIGHT" "FAIR" OR
"FLUENT")
LANGUAGE ...411-44-a- SPEAK AZ2-4-4 READ WRITE Ta:41
LANGUAGE
LANGUAGE
SPEAK READ WRITE
SPEAK READ WRITE
B. LIST ALL SPORTS AND HOBBIES WHICH INTEREST YOU: INDICATE DEGREE OF PROFI-
CIENCY IN EAU ei....4�0 (5 )
C. HAVE YOU ANY QUALIFICATIONS, AS A RESULT OF TRAINING OR EXPERIENCE, WHICH
MIGHT FIT YOU FOR A PARTICULAR POSITION?
..124-4-e-w1-2-cte,"-
4A-e-InA-12-4-e4-L-4-4-7. 7 _1( 5. ep-e-&-re-c-a
eveze..,,P2y,
D. LIST BELOW NAMES OF GOVERNMENT DEPARTMENTS, AGENCIES OR OFFICES TO
WHICH YOU HAVE APPLIED FOR EMPLOYMENT SINCE 1939:
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:
1-re-41fr --(.4.f.GLe�-�12e-r4.4e
et-16-e_A-40 132a-e-A-e&Ge--t-Z-0--ert-
e eArl-e-1
11
FDPS 17
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� 12
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'
No.
B. DO YOU.USE, OR HAVE ;YOU USED, INTOXICANTS?
EXTENT?
111,41-40 02-0_0-4�t�crvt-
IF SO, TO WHAT
C. HAVE YOU EVER BEEN ARRESTED, INDICTED OR CONVICTED FOR ANY VIOLATION OF
LAW OTT= THAN A MINOR TRAFFIC VIOLATION? IF SO, STATE NAME OF COURT,
CITY, STATE, COUNTRY, NATURE OF OFFENSE AND DISPOSITION OF CASE:
,klo.
D. HAVE YOU EVER BEEN COURT-MARTIALED WHILE A MEMBER OF THE ARMED FORCES?
IF ANSWER IS "YES," GIVE DETAILS BELOW:
Ai
SEC. 25. PERSON TO BE NOTIFIED IN CASE OF EMERGENCY:
NAME _ RELATIO
ADDRESS
OS. 4Z CIO.
caw ISTALE
Country
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
INVOLVEII OR NOT, wincH MIGHT REQUIRE EXPLANATION? IF SO, DESCRIBE. IF NOT, AN-
SWER "NO."
FOPS 18
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SEC. 27. I CERTIFY THAT THE FOREGOING ANSWERS ARE TRUE AND CORRECT TO THE
BEST OF MY KNOWLEDGE AND BFTaw', AND I AGREE THAT ANY MISSTATEMENT
OR OMISS.ION AS TO A MATERIAL FACT WILL CONSTITUTE GROUNDS FOR IM-
MEDIATE DISMISSAL OR REJECTION OF MY APPLICATION.
SIGNED AT
Witness
741-a4-44-t.
City
7)� C � DATE
USE THE FOLLOWING PAGES FOR EXTRA DETAILS. NUMBER ACCORDING TO THE NUMBER
OF THE QUESTION TO WHICH THEY RELATE. SIGN YOUR NAME AT THE END OF THE ADDED
MATERIAL. IF ADDITIONAL SPACE IS REQUIRED USE EXTRA PAGES THE SAME SIZE AS
THESE AND SIGN EACH SUCH PAGE.
13
FOPS 19
(b)(6)
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