INSTRUCTION FOR FILLING OUT CIA APPLICATION

• Document Type: CREST
• Collection: General CIA Records
• Document Number (FOIA) /ESDN (CREST): CIA-RDP79-00632A000100070010-2
• Release Decision: RIFPUB
• Original Classification: U
• Document Page Count: 45
• Document Creation Date: December 12, 2016
• Document Release Date: November 26, 2001
• Sequence Number: 10
• Content Type: REQ

Approved For Release 2002/01/08 : CIA-RDP79-00632A000100070010-2
READ THIS FIRST
THE FOLLOWING INSTRUCTIONS SHOULD BE READ CAREFULLY. YOUR APPLICATION WILL NOT BE ACTED UPON UNTIL
ALL QUESTIONS HAVE BEEN ANSWERED AND ALL DOCUMENTS RECEIVED.
1. Applicant Information Sheets No. 1 and No. 2
Read both Applicant Information Sheets. Sign and return one (1) copy of Sheet No. 1. You may
retain Sheet No. 2 and the second copy of Sheet No. 1.
2. Personal History Statement
Type or print carefully. USE BLACK TYPEWRITER RIBBON OR BLACK INK. Complete and return only
one copy. It must be signed and witnessed. The other copy may be used as a worksheet and
retained for your own records.
Appendix 1 to the Personal History Statement
Read Appendix 1 carefully and return signed and witnessed. If you are married, Appendix 1 is
also to be read by your spouse and signed and witnessed in the section provided.
4. Medical Record (Form 2223)
a. This form is to be completed by you. You have the option, however, of:
1. Completing it now, enclosing in the envelope provided marked "Privileged Medical in-
formation," sealing and submitting it with your other application papers; or
2. Completing it at the time of subsequent medical examination.
Completing the form now may mean a saving in processing time and thus be to your personal
advantage, particularly if there is any question concerning physical qualifications that
must be resolved.
b. If you desire to complete the form now, proceed as follows:
1. Answer all items
2. Each item checked in Section 6 requires explanation of the following points on the
reverse side of the form:
a. Age when occurred
b. Exact diagnosis if known
c. Type of treatment
d. Name and address of physician who treated
e. Remaining defects
3. If you have ever been hospitalized for a psychiatric or emotional problem or if you
have ever consulted a psychiatrist or psychologist for any reason other than voca-
tional counseling, provide a complete and detailed report in your own words covering
such hospitalization or consultation.. Use the reverse side of the form. If addi-
tional space is needed, use a continuation sheet, sign it and attach to the form.
4. If you are presently under the care of a physician for other than a minor ailment,
attach a statement from this physician describing the condition.
Photographs
Please furnish three (3) passport-size photographs (head and shoulders view 2=" X 24" mini-
mum size). On the back of each photograph, indicate date taken and print your name.
6. College Transcript
If you have not been instructed otherwise, please include one (1) copy of your college tran-
script (including graduate work, if appropriate). If you are enrolled in courses which do
not appear on the transcript, please list these courses and attach the list to the transcript.
If a transcript will be forwarded later, please indicate the approximate date.
FORM UR VadLFE Qt Release 2002/01/08 : CIA-RDP79-00632A000100070010-2
EDITIONS
 Approved For Release 2002/01/08 : CIA-RDP79-00632A000100070010-2
CENTRAL INTELLIGENCE AGENCY
WASHINGTON, D. C. 20505
Applicant Information
Sheet No. 1
To all persons applying for employment
with the Central Intelligence Agency:
This paper is the first step in applying for employment or con-
sultant status with the Central Intelligence Agency. No application may
proceed beyond this first step if the applicant is not in agreement with
the conditions stated below:
General Considerations:
1. The National Security Act of 26 July 1947 (Public Law 253, 80th
Congress) which created the Central Intelligence Agency places upon the
Agency the responsibility:
a. "to advise the National Security Council in matters concern-
ing such intelligence activities of the Government departments
and agencies as relate to the national security;
b. "to make recommendations to the National Security Council
for the coordination of such intelligence activities of the
departments and agencies of the Government as relate to
the national security;
c. "to correlate and evaluate intelligence relating to the national
security, and provide for the appropriate dissemination of
such'intelligence within the Government ... ;
d. "to perform, for the benefit of the existing intelligence
agencies, such additional services of common concern as the
National Security Council determines can be more efficiently
accomplished centrally;
e. "to perform such other functions and duties related to intelli-
gence affecting the national security as the National Security
Council may from time to time direct."
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 Approved For Release 2002/01/08 : CIA-RDP79-00632A000100070010-2
The special character of this national responsibility requires the Agency
to maintain special employment criteria which may be different from the
routine or normal employment standards of other Government departments
and agencies which do not have the highly sensitive responsibility borne by
the Central Intelligence Agency. It follows that the investigation of ap-
plicants prerequisite to their acceptance is a time-consuming process
which, in addition to loyalty and security checks, includes evaluation of
competence, physical and emotional fitness, and availability of a suitable
position at such time as employment may be offered. This is called
"Clearance" of an applicant.
2. This comprehensive review may result in a determination that
an applicant is not acceptable under the special employment criteria of the
Agency. Frequently, such determination would not be the result of any
single event or element in the applicant's personal background or quali-
fications but would reflect the composite results of the several evaluations
involved. In any event, adverse findings by the Agency are conclusive and
final so far as the Agency is concerned, and no statement of specific reasons
is made to the applicant.
3. It should be understood by each applicant that appointments are
extremely competitive and that not everyone who is investigated is finally
employed. Employment by the Central Intelligence Agency is not a right
upon which an applicant can insist. An offer of employment which is subject
to full clearance does not constitute a commitment on the Agency's part
giving an unsuccessful applicant grounds for any claim against the Agency.
Acceptance of employment upon the condition of clearance is at the ap-
plicant's risk, taken with the knowledge that a very substantial percentage
of applicants are not appointed.
Statement of Understanding
and Agreement
I have read, understand, and agree to the foregoing General Considera-
tions. If not accepted for employment by the Central Intelligence Agency, I
will make no claim or demand in conflict with those considerations.
I have also seen and read Applicant Information Sheet No. 2.
(Signature of Applicant)
Approved For Release 2002/01/08 : CIA-RDP79-00632A000100070010-2
 Approved6g1q~"Ac2 1.M8L q a-0ft 0070010-2
WASHINGTON, D. C. 20505
Applicant Information
Sheet No. 2
1. In accordance with its special national responsibilities, the Central
Intelligence Agency is obliged to judge carefully the suitability of each
person selected for employment in the Agency. To assist in this determina-
tion, an extensive investigation, which includes a polygraph interview, is
conducted with regard to the loyalty, background, and character of appli-
cants under consideration for employment with the Agency. This in-
vestigation includes, but is not limited to, inquiries concerning:
a. professional competence
b. any behavior, activities or associations which tend to show that
the individual is of questionable character, discretion, integrity
or trustworthiness
c. any deliberate misrepresentations, falsifications, or omission
of material facts
d. any criminal, infamous, dishonest, immoral, or notoriously dis-
graceful conduct, habitual use of intoxicants to excess, drug
addiction, or sexual perversion
e. physical fitness
f.
an adjudication of insanity, serious mental illnesses, neurolog-
ical disorders, or emotional instability
g.
any
may
may
facts which furnish reason to believe that the individual
be subjected to coercion, influence, or pressure which
cause him to act contrary to the best interests of the na-
tional security
h. commission of any act of sabotage, espionage, treason, or sedi-
tion, or attempts thereat or preparation therefor, or conspiring
with, or aiding or abetting, another to commit or attempt to com-
mit any act of sabotage, espionage, treason, or sedition
i. establishing or continuing a sympathetic association with a
saboteur, spy, traitor, seditionist, anarchist, or revolutionist,
(over)
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 Approved For Release 2002/01/08 : CIA-RDP79-00632A000100070010-2
or with an espionage or other secret agent or representative
of a foreign nation, or any representative of a foreign nation
whose interests may be inimical to the interests of the United
States,. or with any person who advocates the use of force or
violence to overthrow the government of the United States or the
alteration of the form of government of the United States by un-
constitutional means
j. advocacy of use of force or violence to overthrow the govern-
ment of the United States, or of the alteration of the form of
government of the United States by unconstitutional means
k. membership in, or affiliation or sympathetic association with,
any foreign or domestic organization, movement, group, or
combination of persons which is totalitarian, Fascist, Com-
munist, or subversive, or which has adopted, or shows, a policy
of advocating or approving the commission of acts of force or
violence to deny other persons their rights under the Constitu-
tion of the United States, or which seeks to alter the form of
government of the United States by unconstitutional means
1. intentional, unauthorized disclosure to any person of security
information, or of other information, disclosure of which is pro-
hibited by law, or willful violation or disregard of security reg-
ulations
m. performing or attempting to perform his duties, or otherwise
acting, so as to serve the interests of another government in
preference to the interests of the United States
2. In considering applicants for employment, Central Intelligence
Agency standards oblige strict interpretation of the above and other factors
involved in selecting employees. In the event an applicant is in doubt
as to whether anything in his background may disqualify him, he is at
liberty to consult a Security, Medical or Personnel Officer of the Agency
and discuss the matter in strict confidence before proceeding with his
application.
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Approved For Release 2002/01/08 : CIA-RDP79-00632A000100070010-2
 Approved For Release 2002/01/08 : CIA-RDP79-00632AM0100070010-2
PERSONAL HISTORY STATEMENT
INSTRUCTIONS
-DO NOT ATTEMPT TO COMPLETE THIS FORM UNTIL YOU HAVE READ THE FOLLOWING INSTRUCTIONS-
1. Answer all questions completely or check (X) the box which applies. If the question is not applicable, write "NA".
If you do not know the answer and it cannot be obtained from personal records, write "Unknown". Use the blank
space on pages 15 and 16 for extra details on any question for which you do not have enough space.
2. Type or pent carefully-USE BLACK TYPEWRITER RIBBON OR BLACK INK.
3. Leave blank any boxes or columns which are marked "FOR OFFICE USE ONLY".
4. Consider each of your answers carefully; accurate completion of the form will permit review of your qualifications to
the best advantage. Your signature at the end of the form will certify to its correctness.
5. Page 17 entitled "Personal History Summary" must be completed. It is a brief abstract of information from other parts
of the form and will help to speed the processing of your application.
1. Full Name (Last-first-middle)
2. Age
3. Sex
^ Male ^ Female
4. Social security number
5. Nicknames
6. Other names you have used
7. Indicate circumstances (including length of time) under which you have used the names noted In item 6 above
8. If legal change of name, give particulars (Where and by what authority)
9. Height
10. Weight
11. Color of eyes
12. Color of hair __
T5, Type of complexion
14. Build
15. Scars (Type and location)
16. Other distinguishing physical features
17. Current address (No., Street, City, State 6 ZIP code-country if not U.S.)
18. Current phone number
19. Long distance
area code
20. Permanent address (No., Street, City, State & ZIP code-country if not U.S.)
21, Permanent phone number
22. Long distance
area code
23. Office phone number
24. Office extension
25. Legal residence (State, territory or country)
1. Indicate the type of work or position for which you are applying
2. Indicate the lowest annual entrance salary you will accept
$
3. Dates available for employment
Earliest: Latest:
4. Indicate your willingness to travel
5. Indicate your willingness to accept assignment in the following locations-check
Occasionally
Other (Specify):
(X) each item applicable
Frequently
Washington, D.C.
Outside continental U.S.
Constantly
Anywhere in U.S.
Certain locations only (Specify):
6. Indicate any restrictions you would place on assignments outside the Washington, D.C. area
(For Office Use Only)
AppCoved For Release 20
02/01/08 : CI -RDP7 -00632A00
Date of this application
100070010-2
FORM USE PREVIOUS
3-66 444 _
EDITIONS
 Approved or Release - -
1. Date of birth
2. Place of birth (City, State, Country)
3. Present citizenship (Country)
4. Citizenship ^ Birth Marriage
acquired by: ^ Other (Specify):
5. Date naturalized
6. Naturalization certificate number
7. Court issuing naturalization certificate
8. Issued at (City, State, Country)
9. If alien, give alien registration number
10. Date and place of arrival In U.S.
11. Have you held previous nationality?
Yes ^ No
12. If yes, give name of country
13. Give particulars concerning previous nationalities
14. Last U.S. visa (Number, type, place of issue)
15. Date visa issued
ELEMENTARY SCHOOL
1. Name of elementary school ,
Address (City, State, Country)
Years attended (From - to -)
Graduate
1-1 Yes
El No
HIGH SCHOOLS
1. Name of high school
Address (City, State, Country)
Years attended (From - to -)
Graduate
^ Yes
D No
2. Name of high school
Address (City, State, Country)
Years attended (From - to -)
Graduate
Yes
No
COLLEGE OR UNIVERSITY STUDY
f
i
it
N
d l
ti
ll
Subject
Years attended
Degree
Year
Grade or
Point
Num er o
Sam
/Qt
ege or un
vers
ame an
oca
on o
co
y
Mayor
Minor
From- to-
Received
Received
Average
.
r.
Hours (Specify)
?
2.
3.
4. If a graduate degree has been noted above which required submission of a written thesis, indicate the title of the thesis and briefly describe its content.
TRADE, COMMERCIAL AND SPECIALIZED SCHOOLS
Name and address of school
Study or specialization
From
To
No. of months
2.
3.
4.
 Approved For Release 2ft%-W8%. RYN& 96619132A666 1000?00 d - -
MILITARY TRAINING IN SPECIALIZED SCHOOLS SUCH AS ORDNANCE, COMMUNICATIONS, ETC.
Name and address of school
Study or specialization
From
To
No. of months
2.
3.
a
Other education or training not indicated above
1.
Level of Skill
List below the foreign language or languages in
(Slight)
(Native)
which you possess any degree of competence. Indi-
1 2 3
4 5
cafe your proficiency in each of the five skill factors
shown (reading comprehension, writing ability, etc.)
l
l
f
f
d
0= No proficiency in a
specific skill factor
your
eve
o
icative o
by noting the number most in
skill under the factor being considered.
-If your proficiency relates to a particular dialect of a
SKILL FACTORS
HOW ACQUIRED
(Check (X) Box(es)
which apply]
major language, identify this dialect by noting it in
parentheses after the language on the same line.
If you have no proficiency in any foreign
language, check (X) box at right and~p.
leave other items blank.
; X,
? ?c
X S e` o e~ F
o yP ? a o` 2~~o a` `ty
7 ""1
2. If you have had experience as a translator, interpreter or Instructor-explain and specify in which language(s) you have had such experience.
3. Describe your ability to do specialized language work Involving vocabularies and terminology in the scientific, engineering, telecommunications, military and otherspecialized fields.
4. If you have noted a proficiency in language, would you be willing to use this ability
in any position for which you might be selected? El Yet El No
(For Office Use Only)
Approved For Release 2002/01/08 : CIA-RDP79-00632AO00100070010-2
 List below any foreign regions or countries In which you have traveled or gained knowledge as a result of residence, study or work assignment. Indicate
type of knowledge such as terrain, harbors, industries, utilities, railroads, political parties, etc.
1.
Name of R
i
T
f S
i
li
d
D
f
Knowledge acquired by-Check (X)
eg
on
or Country
ype o
pec
a
ze
Knowledge
ates o
Travel
or Residence
Dates & Place
of Study
Resi-
deuce
Travel
Study
Work
Assign-
ment
?
?
2. Indicate the purpose of visit, residence or travel In each of the regions or countries listed above
3. United States Passport Number & Expiration Date, if Issued
1. Typing (WPM) 2. Shorthand (WPM)
3. Indicate shorthand system used-check (X) appropriate item: Other-
Gregg ^ Speedwriting ^ Stenotype ^ Specify:
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 business equipment or machines which you may have listed in Item 4, section VII, list any special skills you possess relating to other equipment and machines such
as operation of radio transmitters (indicate CW speed, sending & receiving), offset press, turret lathe, EDP and other scientific & professional devices.
4. Are you now or have you ever been a licensed or certified member of any trade or profession such as pilot, electrician, radio operator, teacher, ^ Yes
lawyer, CPA, medical technician, psychologist, physician, etc.? ? ^ No
5. If you have answered "Yes" to item 4 above, Indicate kind of license or certification and the issuing State, municipality, etc.
(Provide license registry number, if known)
6. First License/Certificate (year of issue)
7. Latest License/Certificate (year of issue)
8. List any significant published materials of which you are the author (do NOT submit copies unless requested). Indicate the title, publication date, and type of writing (non-
fiction or scientific articles, general interest subjects, novels, short stories, etc.)
9. Indicate any devices which you have Invented and state whether or not they are patented.
10. List public speaking and public relations experience.
11. List any honorary associations or societies of which you are now or were formerly a member. List academic honors you have received.
A 12 proved We I VOPMLLP-G%lP7FPBWMA AV41D0070010-2
-4
 SECTION IX MILITARY SERVICE
CURRENT DRAFT STATUS
1. Are you registered for the Draft under the Uni-
l Milit
T
i
i
& S
i
A
t
yes
2. Selective Service classification
3. If deferred, give reason
'
verna
ary
ra
n
ng
ce
c
, as
erv
amended?
No
4. Local Selective Service Board Number and Address
MILITARY SERVICE RECORD
Complete the following items for current and/or past active duty military service with the Army, Navy, Air Force, Marine Corps, Coast Guard, Merchant
Marine, National Guard, Air National Guard, or foreign (non-U.S.) military organization. For foreign military organization, specify both nationality
and organization in Item 1 below.
1. Military organization (Army, Navy, etc.-specify)
2. Branch or Corps
3. Dates of service (extended active duty)
From- To-
4. Status (Regular, Reserve, etc.-
5. Rank, grade or rate (at separa-
6. Serial, service or file number
7. Type of separation from
specify)
tion if past service)
active duty (insert number for
type which applies-see
list below)
8. Brief description of military duties (record the duties and skills which best describe your work or function in the military service)
(1)
1. Military organization (Army, Navy, etc.-specify)
2. Branch or Corps
3. Dates of service (extended active duty)
from- To-
4. Status (Regular, Reserve, etc.-
5. Rank, grade or rate (at separa-
6. Serial, service or file number
7. Type of separation from
specify)
tion if past service)
active duty (insert number for
type which applies-see
list below)
8. Brief description of military duties
(2
Types of separation from
7-Undue hardships
1 -Honorable discharge 4-Retirement for service
active duty-record
-Other-specify in
2-Release to inactive duty 5-Retirement for combat disability
applicable number in
3-Retirement for age 6-Retirement for physical disability item 7 in lieu of
item(s) 7 above
number
MILITARY RESERVE, NATIONAL GUARD & R.O.T.C. STATUS
Complete the following Items If (1) you now have reserve status, (2) you are a member of the National Guard or Air National Guard, or (3) you are a
member of the ROTC.
Check (X) Reserve, Guard or'
ROTC or
anization to which
Army
Marine Corps
National Guard
Coast Guard
Navy ROTC
g
Navy
Air Force
it at uar
Army ROTC
Air Force
ROTC
you belong
1. Current rank, grade or rate
2. Date of appointment in current rank
3. Expiration date of current
reserve obligation
4. Check (X) current reserve category 0111. 0 Ready Reserve j Standby (active) J Standby (inactive) ^ Retired
5. Brief description of military reserve duties (record the duties and skills which best describe your work or function In the military service)
6. If you are currently assigned to a Reserve, National Guard, or ROTC Training Unit,
7. If you have a military mobilization assignment, identify the unit and its address
identify the unit and its address
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-RDP79-00632A000100070010-2
 NOTE: LIST LAST POSITION FIRST. Indicate chronological history of employment for past 15-years, starting with current or most recent position. Account
for all periods including casual employment and all periods of unemployment. Give address and state what you did during periods of unemploy-
ment. List all civilian employment by a foreign government, regardless of dates. In completing item 10, "description of duties", consider your
experience carefully and provide meaningful, objective statements.
1. Inclusive dates (From- to- by month & year)
2. Name of employing firm or agency
3. Address (Number, Street, City, State, Country)
4. Indicate specific area or place of employment if other than address noted in item 3
5. Kind of business
6. Name of supervisor ^ Male
^ Female
(~)
7. Title of job
8. Salary or earnings
9. Class; grade if Federal Service
$ per
10. Description of duties
11. Reasons for leaving
1. Inclusive dates (From- to- by month & year)
2. Name of employing firm or agency
3. Address (Number, Street, City, State, Country)
4. Indicate specific area or place of employment if other than address noted in item 3
5. Kind of business
6. Name of supervisor ^ Male
^ Female
(2)
7. Title of job
S. Salary or earnings
9. Class; grade if Federal Service
f per
10. Description of duties
11. Reasons for leaving
1. Inclusive dates (From- to- by month & year)
2. Name of employing firm or agency
3. Address (Number, Street, City, State, Country)
4. Indicate specific area or place of employment if other than address noted in item 3
5. Kind of business
6. Name of supervisor ^ Male
^ Female
(3)
7. Title of job
8. Salary or earnings
9. Class, grade if Federal Service
per
10. Description of duties
11. Reasons for leaving
1. Inclusive dates (From- to- by month & year)
2. Name of employing firm or agency
3. Address (Number, Street, City, State, Country)
4. Indicate specific area or place of employment if other than address noted in item 3
(4)
5. Kind of business
6. Name of supervisor ^ Male
^ Female
7. Title of job
8. Salary or earnings
9. Class; grade if Federal Service
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10-2
A roved For Release 20&PWMN1/F)pSP'79-00632A000100070010-2
-6 -
 EMPLOYMENT HISTORY (Continued)
(4)
10. Description of du proved or Release 2002101108 - - -
11. Reasons for leaving
1. Inclusive dates (Mm- to- by month 8 year)
2. Name of employing firm or agency
3. Address (Number, Street, City, State, Country)
4. Indicate specific area or place of employment if other than address noted in item 3
5. Kind of business
6. Name of supervisor ^ Male
^ Female
(5)
7. Title of lob
B. Salary or earnings
$ per
9. Class; grade if Federal Service
10. Description of duties
It. Reasons for leaving
1. Inclusive dates (From- to- by month & year)
2. Name of employing firm or agency
3. Address (Number, Street, City, State, Country)
4. Indicate specific area or place of employment if other than address noted in item 3
5. Kind of business
6. Name of supervisor ^ Male
^ Female
(6)
7. Title of lob
8. Salary or earnings
$ per
9. Class; grade if Federal Service
10. Description of duties
11. Reasons for leaving
1. Inclusive dates (From- to- by month & year)
2. Name of employing firm or agency
3. Address (Number, Street, City, State, Country)
4. Indicate specific area or place of employment if other than address noted in item 3
S. Kind of business
6. Name of supervisor ^ Male
^ Female
(1)
7. Title of lob
B. Salary or earnings
$ per
9. Class; grade if Federal Service
10. Description of duties
11. Reasons for leaving
If prior service with the Federal Government Is noted above, Indicate the number of years creditable
toward U.S. Civil Service Retirement, If known.
(For Office Use Only)
Approved For Release 2002/01/08 : CIA-RDP79-00632A000100070010-2
 1. Present status (Single, married, widowed, separated, divorced, annulled, remarried) specify
2. State date, place, and reason for all separation, divorces or annulments
Wife, husband
or fiance(e)
If you have been married more than once (including annulments) use separate sheet for former wife or husband giving data required
below for all previous marriages. If marriage contemplated, fill In appropriate information for fiance(e).
3. Name of spouse (Lost) (First) (Middle) (Maiden)
4. State any other names ever used by spouse
Indicate circumstances (including length of time) under which any names noted In Item 4 above were used. If legal change, give particulars (where
and by what authority). Use extra space provided on pages 15 and 16 of this form to record this Information.
5. Date of birth
6. Place of birth (City, State, Country)
7. Date of marriage
8. Place of marriage (City, State, Country)
9. Living
Yes 1:1 No
10. Citizenship
11. Former citizenship(s) [country(ies)]
12. If alien, give alien registration number
13. Date U.S. citizenship acquired
14. Where acquired
15. Date and place of arrival in U.S.
16. Naturalization certificate number
17. Date of death
18. Cause of death
19. Current address (Give lost address, if deceased)
20. Address of spouse before marriage
21. Occupation
22. Present employer (Also give former employer, or if spouse deceased or unemployed, give last two employers)
23. Employer's or business address (Number, Street, City, Stale, Country)
24. Dates of military service
(From - to - by month & year)
25. trench of military service
26. Country with which military service affiliated
27. Details of other government service, U.S. or foreign
1. Provide the following information for all children and dependents:
Name
Relationship
Date & Place of Birth
Citizenship
Address
2. No. of children (include stepchildren 6 adopted children) who are
unmarried, under 21 years of age, and are NOT self-supporting,
Approved For Releas 20
3. No. of other dependents (e.g., spouse, parents, stepparents, etc.)
who depend on you for at least 50% of their support or children over pop
0100070 10-2
 1. Full name (Last-First-Middle)
2. State other names he has used
Indicate circumstances (including length of time) under which any names In item 2 above were used. If legal change, give particulars (where and by
what authority). Use extra space provided on pages 15 and 16 of this farm to record this Information.
3. Date of birth
4. Place of birth (City, State, Country)
5. Living
^ Yes ^ No
6. Date of death
7. Cause of death
8. Citizenship (Country)
9. Former citizenship(s) [country(ies)]
10. Date U.S. citizenship acquired
11. Where acquired (City, State, Country)
12. Naturalization certificate number
13. If alien, give alien registration number
14. Date and place of arrival in U.S.
15. Current address (Give last address, if deceased)
16. Occupation
17. Present employer (Give last employer if father deceased or unemployed)
18. Employer's business address or father's business address If self-employed
19. Dates of military service (From - to -)
20. Branch of military service
21. Country with which affiliated
22. Details of other government service, U.S. or foreign
1. Full name (Last-First-Middle-Maiden)
2. State other names she has used
Indicate circumstances (including length,of time) under which any names noted in item 2 above were used. If legal change, give particulars (where and
by what authority). Use extra space provided on pages 15 and 16 of this form to record this information.
3. Date of birth
4. Place of birth
5. Living
^ Yes ^ No
6. Date of death
7. Cause of death
8. Citizenship (Country)
9. Former citizenship(s) [country(ies)]
10. Date U.S. citizenship acquired
11. Where acquired (City, State, Country)
12. Naturalization certificate number
13. If alien, give alien registration number
14. Dote and place of arrival in U.S.
? 15. Current address (Give last address, if deceased)
16. Occupation
17. Present employer (Give last employer if mother deceased or unemployed)
18. Employer's business address or mother's business address if self-employed
19. Dates of military service (From - to -)
20. Branch of military service
21. Country with which affiliated
22. Details of other government service, U.S. or foreign
Approved For Release 2002/01/08 : CIA-RDP79-00632A000100070010-2
Approved For Release 2002/01/08: CIA-RDP79-00632AY00100070010-2
FATHER (Give some information for stepfather and/or guardian on a separate sheet)
MOTHER (Give some information for stepmother on a separate sheet)
 1. Full name (Last-First-Middle-Maiden)
2. Relationship
3. Citizenship (Country)
(1)
4. Date of birth
5. Place of birth (City, Slate, Country)
6. Living
^ Yes ^ No
7. Present employer (Give last employer if deceased or unemployed)
S. Current address (Give last address, if deceased)
1. Full name (Lost-First-Middle-Maiden)
2. Relationship
3. Citizenship (Country)
(Z)
4. Date of birth
5. Place of birth (City, State, Country)
6. Living
^ You ^ No
7. Present employer (Give last employer if deceased or unemployed)
8. Current address (Give last address, if deceased)
1. Full name (Last-First-Middle-Maiden)
2. Relationship
3. Citizenship (Country)
(3)
4. Date of birth
5. Place of birth (City, State, Country)
6. Living
^ Yes ^ No
7. Present employer (Give last employer if deceased or unemployed)
8. Current address (Give last address, if deceased)
1. Full name (Last-First-Middle-Maiden)
2. Relationship
3. Citizenship (Country)
(4)
4. Date of birth
5. Place of birth (City, State, Country)
6. Living
^ Yes ^ No
?
7. Present employer (Give last employer if deceased or unemployed)
B. Current address (Give last address, if deceased)
1. Full name (Last-First-Middle-Maiden)
2. Relationship
3. Citizenship (Country)
(5)
4. Date of birth
5. Place of birth (City, State, Country)
6. Living
^ Yes ^ No
7. Present employer (Give last employer if deceased or unemployed)
B. Current address (Give last address, if deceased)
1. Full name (Lost-First-Middle-Maiden)
2. Relationship
3. Citizenship (Country)
(6)
4. Date of birth
5. Place of birth (City, State, Country)
6. Living
^ Yes ^ No
7. Present employer (Give last employer if deceased or unemployed)
8. Current address (Give last address, if deceased)
A P8 HW6 ASR
1. Full name (Lost-First-Middle)
2. State other names he has used
Indicate circumstances (including length of time) under which any names noted In item 2 above were used. If legal change, give particulars (where and
by what authority). Use extra space provided on pages 15 and 16 of this form to record this information.
3. Date of birth
4. Place of birth
5. Living
^ Yes ^ No
6. Date of death
7. Cause of death
B. Citizenship (Country)
9. Former citizenship(s) [country(les)]
10. Date U.S. citizenship acquired
11. Where acquired (City, State, Country)
12. Naturalization certificate number
13. If alien, give alien registration number
14. Date and place of arrival in U.S.
15. Occupation
16. Present employer (Give last employer if father-in-law deceased or unemployed)
17. Current address (Give last address, if deceased)
(For Office Use Only)
Approved or a ease _ U = - 00070010-2
vase
1Al2R0Fb7j?*dA)5ft-8 0110010-2
0 6
 1. Full name (Lost-First-Middle-Maiden)
2. State other names she has used
Indicate circumstances (including length of time) under which any names noted in item 2 above were used. If legal change, give particulars (where and
by what authority). Use extra space provided on pages 15 and 16 of this form to record this information.
3. Date of birth
4. Place of birth
5. Living
^ Yes ^ No
6. Date of death
7. Cause of death
S. Citizenship (Country)
9. Former citizenship(s) [country(ies)]
10. Date U.S. citizenship acquired
11. Where acquired (City, State, Country)
12. Naturalization certificate number
13. If alien, give alien registration number
14. Data and place of arrival in U.S.
15. Occupation
16. Present employer (Give last employer if mother-in-law deceased or unemployed)
17. Current address (Give last address, if deceased)
Approved For Rreleace 2002/01/08 - CIA-RDP79-00632W0100070010-2
RELATIVES BY BLOOD, MARRIAGE OR ADOPTION WHO EITHER (1) LIVE ABROAD,
(2) ARE NOT U.S. CITIZENS OR (3) WORK FOR A FOREIGN GOVERNMENT
1. Name (Last-First-Middle) T
2. Relationship
3. Date of birth
4. Place of birth (City, State, Country)
(1)
5. Citizenship (Country)
6. Address or country In which relative resides
7. Employed by
8. Frequency of contact
9. Date of last contact
e
1. Name (Last-First-Middle)
2. Relationship
3. Date of birth
4. Place of birth (City, State, Country)
(2)
5. Citizenship (Country)
6. Address or country in which relative resides
7. Employed by
8. Frequency of contact
9. Date of last contact
1. Name (Lost-First-Middle)
2. Relationship
3. Date of birth
4. Place of birth (City, State, Country)
(3)
5. Citizenship (Country)
6. Address or country in which relative resides
7. Employed by
S. Frequency of contact 7
;7 Date of last contact
RELATIVES BY BLOOD, MARRIAGE OR ADOPTION WHO ARE IN THE MILITARY OR CIVIL
SERVICE OF THE UNITED STATES
-7 1. Name (Last-First-Middle)
2. Relationship
3. Date of birth
4. Place of birth (City, State, Country)
(1)
5. Citizenship (Country)
6. Address (Number, Street, City, State, Country)
7. Type and location of service (If known)
1. Name (Last-First-Middle)
2. Relationship
3. Date of birth
4. Place of birth (City, State, Country)
(2)
5. Citizenship (Country)
b. Address (Number, Street, City, State, Country)
7. Type and location of service (If known)
e
1. Name (Last-First-Middle)
2. Relationship
3. Date of birth
4. Place of birth (City, State, Country)
(3)
5. Citizenship (Country)
6. Address (Number, Street, City, State, Country)
7. Type and location of service (If known)
(For Office Use Only)
Approved For Release 2002/01/08 : CIA-RDP79-00632A000100070010-2
 Include addresses while at school and in military service. If residences in military service cannot be shown as street addresses, indicate complete military unit designation and
location by city, state, and country.
Address-last residence first (number, street, city, state, country)
Inclusive dates (month & year)
From-
To-
Ap roveaAEUiARdt 20D MC:CF MWVA 632 $00070010-2
1. List five character references (not relatives) in the U.S. who know you well
Name (Lost-First-Middle)
Sex
Business Address
Residence Address
Length of Time
Known (in yrs)
M
F
M
F
M
F
M
F
M
F
2. List five persons in the U.S. who know you socially (not relatives, supervisors or employers). If you have resided overseas at any time during the past 15 years, two of the
persons listed (if possible) should be individuals who knew you overseas.
Name (Last-First-Middle)
Sex
Business Address
Residence Address
Length of Time
Known (in yrs)
M
F
M
F
M
F
M
F
M
ZUUZ/ULIUS LA-aooo,ooo,oo,o-,
 Approved For lease 2002/01/08 : CIA-RDP79-006320100070010-2
CLUBS, SOCIETIES, AND OTHER ORGANIZATIONS
SECTION XXIII FINANCIAL STATUS
1, Are you entirely dependent on your salary? Yes No ,~= Rt,- r22..3
2. If your answer is "NO" to the above, state sources of other income
3. Credit references (banking institutions, charge accounts, etc.)
Name of Institution
Address (City, State, Country)
4. Have you ever been in, or petitioned for, bankruptcy? Yes ^ No
S. If your answer Is "YES" to the above, give particulars, Including court and date(s)
6. Do you receive an annuity from the United States or District of Columbia Government under any retirement act, pension, or compensation for military or naval service?
^ Yes ^ No
7. If your answer Is "YES" to the above question, give complete details
8. Do you have any financial Interest In, or official connections with, non.U.S. corporations or businesses or with U.S. corporations or businesses having substantial foreign
interests? ^ Yes No (If answer is "YES", furnish details in space below-Continue on separate sheet, if necessary)
11
1. Do you advocate or have you ever advocated, or are you now or have you ever been a member of, or have you ever supported or been associated
with any political party, Individual or organization which advocates or teaches the overthrown of the government of the United States by force,
violence, or other unconstitutional means, or seeks by force or violence to deny persons their rights under the Constitution of the United States? Yes ^ No
Approved For Release 2002/01/08 : CIA-RDP79-00632A000100070010-2
-13-
 Approve - -
3. Do you use or have you Yes
4. If so, to what extent?
ever used intoxicants? N.
5. Do you use or have you U Yes
6. If so, to what extent?
ever used narcotics? No
7. Have you ever been a member of, or supported, or had any connections with a foreign intelligence organization or its activities? If answer is "Yes", give complete detailss
Yes
No
8. List the names of Government departments, agencies or offices to which you have applied for employment since 1955.
9. If to your knowledge, any of the above have conducted an Investigation of you, Indicate the name of the agency and the approximate date of the investigation.
Note Special
if your answer Is "Yes" to the following questions 10, 11 or 12, provide the Information requested for each question on a separate,
Instructions
signed sheet and attach the sheet to this form In a sealed envelope.
10. Have you ever been convicted in the U. S. or abroad of an offense against the low or forfeited collateral, or are you now under charges Yes
for any offense against the law? (You may omit traffic violations for which you paid a fine of $30.00 or less.) If so, state name of court, city,
U No
state, country, date nature of offense, and disposition of case In accordance with special instructions above.
11. While in the military service, were you ever convicted by special or general court martial? If so, describe incident(s) and provide date(s) of El Yes
occurrence on separate sheet in accordance with instructions above. No
12. Are there any incidents in your life fnot mentioned above) which may come to light In subsequent investigation, whether you were directly fl Yes
involved or not, which you desire to explain? If so, describe Incident(s) and provide date(s) of occurrencels) on separate sheet In accordance ^ No
with special instructions above.
13. Have you ever been dismissed or asked to resign from any position? El Yes U No
Have you left a position under circumstances which you desire to explain? Yes U No
14. If your answer to either or both questions in Item 13 above is "Yes, give details.
7. In case of emergency, other close relatives (spouse, mother, father ...) may also be notified. If such notification is NOT desirable because of health or other reasons,
please identify the persons not to be notified and the reason.
WILL BE INVESTIGATED
that any misstatement or omission as to material fact will constitute grounds for refection of my application or for Immediate dismissal if employed.
Approved For Release 2002/040814G4A-RDP79-00632A000100070010-2
-ftwl
 0100070010-2
Approved For Rase 2002/01/08 : CIA-RDP79-00632A
Use the following space for extra details. Reference each continued item by the section and item number to which it relates and sign your name
at the end of the material. If additional space is required beyond page 16, use extra pages the same size as this page and sign each such page.
Approved For Release 2002/01/08 : CIA-RDP79-00632A00(ft00010-2
Space for extra details continued on page 16
 Approved For Release 2002/01.1081:da4A-RDP79-00632A000100070010-2
 Approved For R-e ease 2002/01/08 : CIA-RDP79-00632A`b~0100070010-2
[Type or print
`carefully-use black Ink]
(For office use only)
(For office use only)
1. Full name (Lost-First-Middle)
?
2. Date of birth
3. Place of birth
4. Other names used (Including maiden name) (Last-First-Middle)
51 Citizenship (If naturalized, indicate date & place of naturalization & certificate no.)
6. Name of spouse (Last-First-Middle-Maiden)
7. Date of birth
8. Place of birth (spouse)
9. Date & place of marriage
10. Citizenship of spouse (If naturalized, indicate date & place of naturalization &
certificate no.)
11. Former spouse(s)-full name(s)
12. If divorced, date & place of divorce
13. Complete following for high school; trade, commercial & specialized schools (Exclude military training); colleges & universities:
Dates attended (From - To -)
?
Name & address of school
Degree received
Major subject
14. Complete following for last three employment positions or last two years-begin with most recent or current position:
Dates employed (Fr
om - To -)
Name & address of employer
Employer's complete business address
15. Record last three places of residence or places of residence for past two years-begin with most recent or current address:
Dates resided (From
- To -)
Complete address (Number, Street, City, State)
(')
16. Military service organization (Army, Navy, etc.-
specify)
17. Serial number
18. Rank, grade or rate
19. Dates of service (From - To -)
(2)
1
20. Military service organization (Army, Navy, etc.-
specify)
21. Serial number
22. Rank, grade or rate
23. Dates of service (From - To -)
24. Father's full name (Last-First-Middle)
25. Date of birth
26. Place of birth (Father)
27. Father's current address (Number, Street, City, State)
28. Father's citizenship (If naturalized, date & place of naturalization & certificate No.)
29. Mother's full name (Last-First-Middle-Maiden)
?
30. Date of birth
31. Place of birth (Mother)
32. Mother's current address (Number, Street, City, State)
33. Mother's citizenship (If naturalized, date & place of naturalization & certificate No.)
PERSONAL HISTORY SUMMARY
Approved For Release 2002/0149817GIA-RDP79-00632A000100070010-2
THIS SHEET MUST BE COMPLETED
 Approved-Ea L-196 WXQOAIff6C~j I MENT 0070010-2
INSTRUCTIONS
-DO NOT ATTEMPT TO COMPLETE THIS FORM UNTIL YOU HAVE READ THE FOLLOWING INSTRUCTIONS-
1. Answer all questions completely or check (X) the box which applies. If the question is not applicable, write "NA".
If you do not know the answer and it cannot be obtained from personal records, write "Unknown". Use the blank
space on pages 15 and 16 for extra details on any question for which you do not have enough space.
2. Type or pent carefully- USE BLACK TYPEWRITER RIBBON OR BLACK INK.
3. Leave blank any boxes or columns which are marked "FOR OFFICE USE ONLY".
4. Consider each of your answers carefully; accurate completion of the form will permit review of your qualifications to
the best advantage. Your signature at the end of the form will certify to its correctness.
5. Page 17 entitled "Personal History Summary" must be completed. It is a brief abstract of information from other parts
of the form and will help to speed the processing of your application.
1 . Full Name (Last-first-middle)
2. Age
3. Sex
1:1 Male ^ Female
4. Social security number
5 . Nicknames
6. Other names you have used
7. Indicate circumstances (including length of lime) under which you have used the names noted in item 6 above
8. If legal change of name, give particulars (Where and by what authority)
9. Height
10. Weight
11. Color of eyes
12. Color of hair
13. Type of complexion
14. Build
15. Scars (Type and location)
16. Other distinguishing physical features
17. Current address (No., Street, City, State & ZIP code-country if not U.S.)
18. Current phone number
19. Long distance
area code
20. Permanent address (No., Street, City, State & ZIP code-country if not U.S.)
21. Permanent phone number
22. Long distance
area code
23. Office phone number
SECT
O
24. Office extension
25. Legal residence (State, territory or country)
I
N II POSITION DATA
1. Indicate the type of work or position for which you are applying
2. Indicate the lowest annual entrance salary you will accept
$
3. Dates available for employment
Earliest: Latest:
on 4. Indicate your willingness to travel
5. Indicate your willingness to accept assignment in the following locations-check
Occasionally
Other (Specify):
(X) each item applicable
Frequently
Washington, D.C.
Outside continental U.S.
Constantly
Anywhere I. U.S.
Certain locations only (Specify):
6. Indicate any restrictions you would place on assignments outside the Washington, D.C. area
(For Office Use Only)
9-00632A0
Date of this application
0100070010-2
FORM
3-66
 SECTION 111 Approved Fo, Release 1
1. Date of birth
2. Place of birth (City, State, Country)
3. Present citizenship (Country)
4? Citizenship Birth ^ Marriage
acquired by: ^ Other (Specify):
5. Date naturalized
6. Naturalization certificate number
7. Court issuing naturalization certificate
B. Issued at (City, State, Country)
9. If alien, give alien registration number
10. Date and place of arrival in U.S.
11. Have you held previous nationality?
11 Yes ^ No
12. If yes, give name of country
13. Give particulars concerning previous nationalities
14. Last U.S. visa (Number, type, place of issue)
15. Date visa issued
ELEMENTARY SCHOOL
1. Name of elementary school,
Address (City, State, Country)
Years attended (From - to -)
Graduate
^ Yes
^ No
HIGH SCHOOLS
1. Name of high school
Address (City, State, Country)
Years attended (From - to -)
Graduate
^ Yes
^ No
2. Name of high school
Address (City, State, Country)
Years attended (From - to -)
Graduate
^ Yes
^ No
COLLEGE OR UNIVERSITY STUDY
i
Su
bject
Years attended
Degree
Year
Grade or
Point
Number of
Sem./Qtr.
ty
Name and location of college or univers
Major
Minor
From- to-
Received
Received
Average
Hours (Specif )
?
2.
3.
4. if a graduate degree has been noted above which required submission of a written thesis, indicate the title of the thesis and briefly describe its content.
TRADE, COMMERCIAL AND SPECIALIZED SCHOOLS
Name and address of school
Study or specialization
From
To
No. of months
2.
3.
4.
 Approved or Release t - CC` I -
MILITARY TRAINING IN SPECIALIZED SCHOOLS SUCH AS ORDNANCE, COMMUNICATIONS, ETC.
Name and address of school
Study or specialization
from
To
No. of months
2.
3.
Other education or training not indicated above
1.
List below the foreign language or languages in
which you possess any degree of competence. Indi-
Lewl of Skill
(slight)
1 2 3
(Native)
4 5
ll
I
I
cate your proficiency in each of the five ski
factors
shown (reading comprehension, writing ability, etc.)
ti
th
b
t i
di
ti
f
l
l
f
b
0 = No proficiency in a
specific skill factor
y no
ng
e num
er mos
n
ca
ve o
your
eve
o
skill under the factor being considered.
SKILL FACTORS
HOW ACQUIRED
[Check (X) Box(es)
If your proficiency relates to a particular dialect of a
which appl
major language, identify this dialect by noting it in
parentheses after the language on the same line.
If you have no proficiency in any foreign
language, check (X) box at right and ---- is. ^
leave other items blank.
r
ro
?{
3` a^
rk o
u r
a> S p e ` e >
o ~, a ,e o~ c ti?
~? ? v
a a > r a S'
2. If you have had experience as a translator, interpreter or Instructor- explain and specify in which language(s) you have had such experience.
3. Describe your ability to do specialized language work involving vocabularies and terminology irs the scientific, engineering, telecommunications, military and other specialized fields.
4. If you hove noted a proficiency in language, would you be willing to use this ability
in any position for which you might be selected?
Yes
-I- ^
No
^
(For Office Use Only)
-3-
 List below any foreign regions or countries In which you have traveled or gained knowledge as a result of residence, study or work assignment. Indicate
type of knowledge such as terrain, harbors, industries, utilities, railroads, political parties, etc.
1.
Knowledge acquired by-Check (X)
Name of Region
or Country
Type of Specialized
Knowledge
Dates of Travel
or Residence
Dates & Place
of Study
Resi-
dence
Travel
Study
Work
Assign.
moot
e
e
?
2. Indicate the purpose of visit, residence or travel in each of the regions or countries listed above
3. United States Passport Number & Expiration Date, If Issued - - - - - - 31111111-
1. List all hobbles 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 business equipment or machines which you may have listed in Item 4, section VII, list any special skills you possess relating to other equipment and machines such
as operation of radio transmitters (indicate CW speed, sending & receiving), offset press, turret lathe, EDP and other scientific & professional devices.
4. Are you now or have you ever been a licensed or certified member of any trade or profession such as pilot, electrician, radio operator, teacher, ^ Yes
Ro.
lawyer, CPA, medical technician, psychologist, physician, etc.?
^ No
5. If you have answered "Yes" to item 4 above, Indicate kind of license or certification and the Issuing State, municipality, etc. 6. First License/Certificate (year of issue)
(Provide license registry number, if known)
7. Latest License/Certificate (year of issue)
9. List any significant published materials of which you are the author (do NOT submit copies unless requested). Indicate the title, publication date, and type of writing (non-
fiction or scientific articles, general Interest subjects, novels, short stories, etc.)
9. Indicate any devices which you have invented and state whether or not they are patented.
10. List public speaking and public relations experience.
11. List any honorary associations or societies of which you are now or were formerly a member. List academic honors you have received.
pprove G p86e% Ib- EDIL,*kNWMIRB[ 21R&0^R000070010-2
_ MX_
U Gregg U Speedwriting U Stenotype U Specify,
 Approved For Relea
se
@Rft(TlAF4RWP7q_00632 0100070010-2
1. Are you registered for the Draft under the Uni-
t
l Milit
T
i
i
& S
i
A
Yes
2. Selective Service classification
3. If deferred, give reason
, as
verna
ary
ra
n
ng
erv
ce
c
amended?
No
4. Local Selective Service Board Number and Address
MILITARY SERVICE RECORD
Complete the following items for current and/or post active duty military service with the Army, Navy, Air Force, Marine Corps, Coast Guard, Merchant
Marine, National Guard, Air National Guard, or foreign (non-U.S.) military organization. For foreign military organization, specify both nationality
and organization in item 1 below.
1. Military organization (Army, Navy, etc.-specify)
2. Branch or Corps
3. Dates of service (extended active duty)
From- To-
4. Status (Regular, Reserve, etc. -
5. Rank, grade or rate (of separa.
6. Serial, service or file number
7. Type of separation from
specify)
tion if past service)
active duty (insert number for
type which applies-see
list below)
8. Brief description of military duties (record the duties and skills which best describe your work or function in the military service)
(1)
1. Military organization (Army, Navy, etc.-specify)
2. Branch or Corps
3. Dates of service (extended active duty)
From - TO-
4. Status (Regular, Reserve, etc.-
5. Rank, grade or rate (at separa-
6. Serial, service or file number
7. Type of separation from
specify)
lion if post service)
active duty (insert number for
type which applies-see
list below)
8. Brief description of military duties
(2
Types of separation from
7-Undue hardships
1-Honorable discharge 4-Retirement for service
active duty -record
-Other-specify in
2-Release to Inactive duty 5-Retirement for combat disability
applicable number in
3-Retirement for age 6-Retirement for physical disability Item 7 in lieu of
item(s) 7 above
number
MILITARY RESERVE, NATIONAL GUARD & R.O.T.C. STATUS
Complete the following items if (1) you now have reserve status, (2) you area member of the National Guard or Air National Guard, or (3) you ore a
member of the ROTC.
Check (X) Reserve, Guard o'
ROTC or
anization to which'
Army
Marine Corps
National Guard
Coast Guard
Navy ROTC
g
Navy
Air force
r at var
Army
Air orce Kul
you belong
1. Current rank, grade or rate
2. Date of appointment in current rank
3. Expiration date of current
reserve obligation
4. Check (X) current reserve category El Ready Reserve Standby (active) Standby (inactive) ^ Retired
5. Brief description of military reserve duties (record the duties and skills which best describe your work or function in the military service)
6. If you are currently assigned to a Reserve, National Guard, or ROTC.Training Unit,
7. If you have a military mobilization assignment, identify the unit and its address
identify the unit and its address
Approved For Release 2002/01/08 : C
A-RDP79-00632A000100070010-2
 Approved For Release 2O 2LOYI'ABNTOWt61RP79-00632A000100070010-2
NOTE: LIST LAST POSITION FIRST. Indicate chronological history of employment for past 13-years, starting with current or most recent position. Account
for all periods including casual employment and all periods of unemployment. Give address and state what you did during periods of unemploy.
ment. List all civilian employment by a foreign government, regardless of dotes. In completing item 10, "description of duties", consider your
experience carefully and provide meaningful, objective statements.
1. Inclusive dates (From- to- by month & year)
2. Name of employing firm or agency
3. Address (Number, Street, City, State, Country)
4. Indicate specific area or place of employment if other than address noted in item 3
5. Kind of business
6. Name of supervisor ^ Male
^ Female
(1)
7. Title of job
8. Salary or earnings
$ per
9. Class; grade if Federal Service
10. Description of duties
11. Reasons for leaving
1. Inclusive dates (From- to- by month & year)
2. Name of employing firm or agency
3. Address (Number, Street, City, State, Country)
4. Indicate specific area or place of employment if other than address noted in item 3
5. Kind of business
6. Name of supervisor ^ Male
^ Female
(2)
7. Title of job
8. Salary or earnings
$ per
9. Class; grade if Federal Service
10. Description of duties
11. Reasons for leaving
1. Inclusive dates (From- to- by month & year)
2. Name of employing firm or agency
3. Address (Number, Street, City, State, Country)
4. Indicate specific area or place of employment if other than address noted in item 3
5. Kind of business
6. Name of supervisor ^ Male
^ Female
(3)
7. Title of job
G. Salary or earnings
$ per
9. Class, grade if Federal Service
10. Description of duties
11. Reasons for leaving
1. Inclusive dates (From- to- by month & year)
2. Name of employing firm or agency
(4)
3. Address (Number, Street, City, State, Country)
4. Indicate specific area or place of employment If other than address noted in item 3
5. Kind of business
6. Name of supervisor ^ Male
E] Female
7. Title of job %~
7 a ary or earn ngs
$ per
. Class; grade if Federal Service
~.. ._
 EMPLOYMENT HISTORY (Continued)
(4)
10. Description of duties
11. Reasons for leaving
1. Inclusive dates (Prom- to- by month year)
Name of employing firm or agency
3. Address (Number, Street, City, State, Country)
4. Indicate specific area or place of employment if other than address noted in item 3
5. Kind of business
6. Name of supervisor Male
Female
(5)
7. Title of job
B. Salary or earnings
$ per
9. Class; grade if Federal Service
10. Description of duties
11. Reasons for leaving
1. Inclusive dotes (From- to- by month & year)
2. Name of employing firm or agency
3. Address (Number, Street, City, State, Country)
4. Indicate specific area or place of employment if other than address noted in item 3
5. Kind of business
6. Name of supervisor El Male
female
(6)
7. Till. of job
8. Salary or earnings
$ per
9. Class; grade If Federal Service
10. Description of duties
11. Reasons for leaving
1. Inclusive dates (From- to- by month i year)
2. Name of employing firm or agency
3. Address (Number, Street, City, State, Country)
4. Indicate specific area or place of employment if other than address noted in item 3
5. Kind of business
6. Name of supervisor ^ Male
Female
(7)
7. Title of job
8. Salary or earnings
$ per
9. Class; grade if Federal Service
10. Description of duties
11. Reasons for leaving
If prior service with the Federal Government Is noted above, indicate the number of years creditable
toward U.S. Civil Service Retirement, If known.
(For Office Use Only)
Approved For Release 2002/01/08 CIA-RDP79-00632A000100070010-2
 S
1. Present status (Single, married, widowed, separated, divorced, annulled, remarried) specify ~~
2. State date, place, and reason for all separation, divorces or annulments
Wife, husband
or fiance(e)
If you have been married mere then once (including annulments) use separate sheet for former wife or husband giving data required
below for all previous marriages. If marriage contemplated, fill In appropriate information for flance(o).
3. Name of spouse (Last) (First) (Middle) (Maiden)
4. State any other names ever used by spouse
Indicate circumstances (including length of time) under which any names noted in Item 4 above were used. If legal change, give particulars (where
and by what authority). Use extra space provided on pages 15 and 16 of this form to record this information.
5. Date of birth
6. Place of birth (City, State, Country)
7. Date of marriage
B. Place of marriage (City, State, Country)
9. Living
^ Yes ^ No
10. Citizenship
11. Former citizenships) [country(ies)]
12. If alien, give alien registration number
13. Date U.S. citizenship acquired
14. Where acquired
15. Date and place of arrival in U.S.
16. Naturalization certificate number
17. Date of death
1B. Cause of death
19. Current address (Give last address, if deceased)
20. Address of spouse before marriage
21. Occupation
22. Present employer (Also give former employer, or if spouse deceased or unemployed, give last two employers)
23. Employer's or business address (Number, Street, City, State, Country)
24. Dates of military service
(From - to - by month & year)
25. Branch of military service
26. Country with which military service affiliated
27. Details of other government service, U.S. or foreign
1. Provide the following information for all children and dependents:
Name
Relationship
Date & Place of Birth
Citizenship
Address
2. No. of children (include stepchildren A adopted children) who are
unmarried, under 21 years of age, and are NOT self-supporting.
3. No. of other dependents (e.g., spouse, parents, stepparents, etc.) -
who depend on you for at least 50% of their support or children over
21 NOT self-supporting.
- S -
 Approved For Release 2002/01/08 : CIA-RDP79-0O632A0001OOO7OO1O-2
1. Full name (Last-First-Middle)
2. State other names he has used
Indicate circumstances (including length of time) under which any names In item 2 above were used. If legal change, give particulars (where and by
what authority). Use extra space provided on pages 13 and 16 of this form to record this Information.
3. Date of birth
4. Place of birth (City, State, Country)
5. Living
^ Yes ^ No
6. Date of death
7. Cause of death
8. Citizenship (Country)
9. Former citizenship(s) [country(ies)] 10. Date U.S. citizenship acquired
11. Where acquired (City, State, Country)
12. Naturalization certificate number 13. If alien, give alien registration number
14. Date and place of arrival in U.S.
15. Current address (Give last address, if deceased)
16. Occupation
T17. Present employer (Give last employer if father deceased or unemployed)
18. Employer's business address or father's business address If self-employed
19. Dates of military service (From - to -)
20. Branch of military service
21. Country with which affiliated
22. Details of other government service, U.S. or foreign
1. Full name (Last-First-Middle-Maiden)
2. State other names she has used
Indicate circumstances (including Iengtb,of time) under which any names noted in Item 2 above were used. If legal change, give particulars (where and
by what authority). Use extra space provided on pages 15 and 16 of this form to record this Information.
3. Date of birth
4. Place of birth
5. Living
^ Yes ^ No
6. Date of death
7. Cause of death
8. Citizenship (Country)
9. Former citizenship(s) [country(ies)]
10, Date U.S. citizenship acquired
11. Where acquired (City, State, Country)
12. Naturalization certificate number
13. If alien, give alien registration number
14. Date and place of arrival in U.S.
? 15. Current address (Give last address, if deceased)
16. Occupation
17. Present employer (Give last employer if mother deceased or unemployed)
18. Employer's business address or mother's business address if self-employed
19. Dates of military service (From - to -)
20. Branch of military service
21. Country with which affiliated
22. Details of other government service, U.S. or foreign
Approved For Release 2002/01/08 : CIA-RDP79-00632AO00100070010-2
 -7 1. Full name (Last-First-Middle-Maiden)
2. Relationship
3. Citizenship (Country)
)
(1)
4. Date of birth
5. Place of birth (City, State, Country)
6. Living
1:1 Yes El No
7. Present employer (Give last employer if deceased or unemployed)
8. Current address (Give last address, if deceased)
1. Full name (Lost-First-Middle -Malden)
2. Relationship
3. Citizenship (Country)
(2)
4. Dote of birth
S. Place of birth (City, State, Country)
6. Living
11 Yes ^ No
7. Present employer (Give last employer if deceased or unemployed)
8. Current address (Give last address, if deceased)
1. Full name (Last-First-Middle-Maiden)
2. Relationship
3. Citizenship (Country)
(3)
4. Date of birth
5. Place of birth (City, State, Country)
6. Living
[:1 Yes ^ No
7. Present employer (Give last employer if deceased or unemployed)
8. Current address (Give last address, if deceased)
1. Full name (Last-First-Middle-Maiden)
2. Relationship
3. Citizenship (Country)
(4)
4. Date of birth
5. Place of birth (City, State, Country)
6. Living
?
^ Yes ^ No
7. Present employer (Give last employer if deceased or unemployed)
S. Current address (Give last address, if deceased)
1. Full name (Last-First-Middle-Maiden)
2. Relationship
3. Citizenship (Country)
(5)
4. Date of birth
5. Place of birth (City, State, Country)
6. Living
^Yes ^No
7. Present employer (Give last employer if deceased or unemployed)
8. Current address (Give last address, if deceased)
1. Full name (Last-First-Middle-Maiden)
2. Relationship
3. Citizenship (Country)
(S)
4. Date of birth
3. Place of birth (City, State, Country)
6. Living
El Yes ^ No
7. Present employer (Give last employer if deceased or unemployed)
B. Current address (Give last address, if deceased)
1. Full name (Last -First -Middle)
2. State other names he has used
Indicate circumstances (including length of time) under which any names noted in item 2 above were used. If'legal change, give particulars (where and
by what authority). Use extra space provided on pages 15 and 16 of this form to record this information.
3. Date of birth
4. Place of birth
5. Living
^ Yes E] No
6. Date of death
7. Cause of death
8. Citizenship (Country)
9. Former citizenship(.) [country(ies)]
10. Date U.S. citizenship acquired
11. Where acquired (City, State, Country)
12. Naturalization certificate number
13. If alien, give alien registration number
14. Date and place of arrival in U.S.
15. Occupation
16. Present employer (Give lost employer if father-in-law deceased or unemployed)
17. Current address (Give last address, if deceased)
(For Office Use Only)
_
Approved For Release 2002/0i.IOSJOCIL.RDP79-00632A000100070010-2
rtr'
 Approved For Release 2002/01/08 : CIA-RDP79-006 000100070010-2
Noe
1. Full name (Last-first-Middle-Maiden)
2. State other names she has used
Indicate circumstances (including length of time) under which any names noted in Item 2 above were used. if legal change, give particulars (where and
by what authority). Use extra space provided on pages 13 and 16 of this form to record this information.
3. Date of birth
4. Place of birth
5. Living
^ Yes ^ No
6. Date of death
7. Cause of death
8. Citizenship (Country)
9. Former citizenship(s) [country(ies)]
10. Date U.S. citizenship acquired
11. Where acquired (City, State, Country)
12. Naturalization certificate number
13. If alien, give alien registration number
14. Date and place of arrival in U.S.
15. Occupation
16. Present employer (Give last employer if mother-in-law deceased or unemployed)
17. Current address (Give fast address, if deceased)
Nd'
RELATIVES BY BLOOD, MARRIAGE OR ADOPTION WHO EITHER (1) LIVE ABROAD,
(2) ARE NOT U.S. CITIZENS OR (3) WORK FOR A FOREIGN GOVERNMENT
1. Name (Last-First-Middle)
2. Relationship
3. Date of birth
4. Place of birth (City, State, Country)
(1)
5. Citizenship (Country)
6. Address or country in which relative resides
7. Employed by
8. Frequency of contact
9. Date of last contact
1. Name (Last-First-Middle)
2. Relationship
3. Date of birth
4. Place of birth (City, State, Country)
?
5. Citizenship (Country)
6. Address or country in.which relative resides
(2)
7. Employed by
8. Frequency of contact
9. Date of last contact
?
1. Name (Last-First-Middle)
2. Relationship
3. Date of birth
4. Place of birth (City, State, Country)
(3)
5. Citizenship (Country)
6. Address or country in which relative resides
7. Employed by 7
8. Frequency of contact
9. Date of last contact
RELATIVES BY BLOOD, MARRIAGE OR ADOPTION WHO ARE IN THE MILITARY OR CIVIL
SERVICE OF THE UNITED STATES
-7 1. Name (Last-First-Middle)
2. Relationship
3. Date of birth
4. Place of birth (City, State, Country)
(1)
5. Citizenship (Country)
6. Address (Number, Street, City, State, Country)
7. Type and location of service (If known)
1. Name (Last-First-Middle)
2. Relationship
3. Date of birth
4. Place of birth (City, State, Country)
(2)
5. Citizenship (Country)
6. Address (Number, Street, City, State, Country)
7. Type and location of service (If known)
?
1. Name (Last-First-Middle)
2. Relationship
3. Date of birth
4. Place of birth (City, State, Country)
(3)
5. Citizenship (Country)
6. Address (Number, Street, City, State, Country)
7. Type and location of service (If known)
(For Office Use Only) Approved For Release 2002/01/08 : CIA-RDP79-00632A000100070010-2
 Include addresses while at school and in military service. If residences in military service cannot be shown as street addresses, indicate complete military unit designation and
location by city, state, and country.
Address-last residence first (number, street, city, state, country)
Inclusive dates (month & year)
From-
To-
A rovedW~'31JNe S2021SS108NCFI DI 9RA9831E4ti09N1D0070010-2
1. List five character references (not relatives) In the U.S. who know you well
Name (Last-First-Middle)
Sex
Business Address
Residence Address
Length of Time
Known (in yrs)
M
F
M
F
M
F
M
F
M
F
2. List five persons in the U.S. who know you socially (not relatives, supervisors or employers). If you have resided overseas at any time during the past 15 years, two of the
persons listed (if possible) should be individuals who knew you overseas.
Name (Last-First-Middle)
Sex
Business Address
Residence Address
Length of Time
Known (in yrs)
M
F
M
F
M
F
M
F
M
F
Approved For FVease 2002/01/08 : CIA-RDP79-00632P 0100070010-2
 ,
,
NOTE: List names and addresses of all clubs, societies, professional societies, employee groups or organizations of any kind to which you belong or
have belonged (Include membership in, or support of, any organization having headquarters or branch in a foreign country).
Name and chapter
Address (Number, Street, City, State, Country)
Date of membership
(From)
(To)
SECTION XXIII FINANCIAL STATUS
1. Are you entirely dependent on your salary? Yes No -? `
2. If your answer is "NO" to the above, state sources of other Income
3. Credit references (banking institutions, charge accounts, etc.)
Name of Institution
Address (City, State, Country)
4. Have you over been In, or petitioned for, bankruptcy? Yes No t d
5. If your answer is "YES" to the above, give particulars, including court and date(s)
6. Do you receive an annuity from the United States or District of Columbia Government under any retirement act, pension, or compensation for military or naval service?
El Yes No
7. If your answer is "YES" to the above question, give complete details
8. Do you have any financial interest in, or official connections with, non-U.S. corporations or businesses or with U.S. corporations or businesses having substantial foreign
interests? Yes n No (If answer is "YES", furnish details in space below-Continue on separate sheet, if necessary)
SECTION XXIV PERSONAL DECLARATIONS
1. Do you advocate or have you ever advocated, or are you now or have you ever been a member of, or have you ever supported or been associated
with any political party, individual or organization which advocates or teaches the overthrown of the government of the United States by force,
violence, or other unconstitutional means, or seeks by force or violence to deny persons their rights under the Constitution of the United States? Yes No
Approved For Release 2002/01/08 : CIA-RDP79-00632 00100070010-2
AND OTHER ORGANIZATIONS
SOCIETIES
CLUBS
Approved For Release 2002/01/08 : CIA-RDP79-00632A000100070010-2
 3. Do you use or have you ^ Yes
4. If so, to what extent?
ever used intoxicants?
No
5. Do you use or have you Yes 6. If so, to what extent?
ever used narcotics? N.
7. Have you ever been a member of, or supported, or had any connections with a foreign Intelligence organization or Its activities? If answer is "Yes", give complete details:
Yes
No
8. List the names of Government departments, agencies or offices to which you have applied for employment since 1955.
9. If to your knowledge, any of the above have conducted an investigation of you, indicate the name of the agency and the approximate date of the investigation.
Note Speci a I
If your answer is "Yes" to the following questions 10, 11 or 12, provide the Information requested for each question on a separate,
Instructions
signed sheet and attach the sheet to this form in a sealed envelope.
10. Have you ever been convicted in the U. S. or abroad of an offense against the law or forfeited collateral, or are you now under charges ^ Yes
for any offense against the low? (You may omit traffic violations for which you paid a fine of $30.00 or less.) If so, state name of court, city,
N
^
o
state, country, date nature of offense, and disposition of case In accordance with special instructions above.
11. While in the military service, were you ever convicted by special or general court martial? If to, describe incident(s) and provide date(s) of jJ Yes
occurrence on separate sheet in accordance with instructions above. No
12. Are there any incidents In your life fnot mentioned above) which may come to light In subsequent investigation, whether you were directly ^ Yes
involved or not, which you desire to explain? If so, describe Incldent(s) and provide date(s) of occurrence(s) on separate sheet in accordance ^ No
ith
i
l instructions above
spec
a
.
w
13. Have you ever been dismissed or asked to resign from any position? ^ Yes El No
Have you left a position under circumstances which you desire to explain? E] Yes ^ No
14. If your answer to either or both questions in Item 13 above is "Yes," give details.
1. Name (Last-First-Middle)
2. Relationship
3. Home address (Number, Street, City, State, ZIP Code)
4. Home telephone number
5. Business address (Number, Street, City, State, ZIP Coda)-indicate name of firm or employer, If applicable
6. Business telephone number & extension
7. In case of emergency, other close relatives (spouse, mother, father ...) may also be notified. If such notification is NOT desirable because of health or other reasons,
please identify the persons not to be notified and the reason.
Approved For Release 2002/OUQBl 4MA-RDP79-00632A000100070010-2
 Approved Forlease 2002/01/08 : CIA-RDP79-00632Af00100070010-2
Use the following space for extra details. Reference each continued item by the section and item number to which it relates and sign your name
at the end of the material. If additional space is required beyond page 16, use extra pages the same size as this page and sign each such page.
Approved For Release 2002/01/08 : CIA-RDP79-00632A000010-2
 (Signature)
Approved For Release 2002/01198!QC1 RDP79-00632A000100070010-2
%O~ 'woe
 V
Approved For Release 2002/01/08: CIA-RDP79-00632A000100070010-2
Type or print
carefully-use black Ink
10. Citizenship of spouse (If naturalized, indicate dote & place of naturalization &
certificate no.)
13. Complete following for high school; trade, commercial & specialized schools (Exclude military training); colleges & universities: J
5. Citizenship (If naturalized, indicate date & place of naturalization & certificate no.)
14. Complete following for last three employment positions or lost two years-begin with most recent or current position: JJ
PERSONAL HISTORY SUMMARY
15. Record last three places of residence or places of residence for past two years-begin with most recent or current address:
16. Military service organization (Army, Navy, etc.-
specify)
20. Military service organization (Army, Navy, etc.-
specify)
24. Father's full name (Last-First-Middle)
28. Father's citizenship (If naturalized, date & place of naturalization & certificate No.)
33. Mother's citizenship (If naturalized,, date & place of naturalization & certificate No.)
Approved For Release 2002/01/08- A-RDP79-00632A000100070010-2
THIS SHEET MUST BE COMPLETED
 Approved FoIease 2002/01/08 : CIA-RDP79-0063M00100070010-2
PERSONAL HISTORY STATEMENT - (Appendix I)
Listed below are names of organizations identified by the Attorney General, under his responsibility pursuant to
Executive Order 10450, dated 27 April 1953, to list the names of each foreign or domestic organization, association,
movement, group or combination of persons which he designates as Totalitarian, Fascist, Communist, or subversive,
or as having adopted or having shown a policy of advocating or approving the commission of acts of force or vio-
lence to deny others their rights under the Constitution of the United States, or as seeking to alter the form of
government of the United States by unconstitutional means.
Each applicant or employee and spouse (if any) must review the following list of organizations for certification
purposes, and sign on the last page.
Abraham Lincoln Brigade
Abraham Lincoln School, Chicago, Illinois
Action Committee to Free Spain Now
Alabama People's Educational Association (see Communist Politi-
cal Association)
American Association for Reconstruction in Yugoslavia, Inc.
American Branch of the Federation of Greek Maritime Unions
American Christian Nationalist Party
American Committee for European Workers' Relief (see Socialist
Workers Party)
American Committee for Protection of Foreign Born
American Committee for Spanish Freedom
American Committee for the Settlement of Jews in Birobidian, Inc.
American Committee for Yugoslav Relief, Inc.
American Committee to Survey Labor Conditions in Europe
American Council for a Democratic Greece, formerly known as the
Greek American Council; Greek American Committee for Na-
tional Unity
American Council on Soviet Relations
American Croatian Congress
American Jewish Labor Council
American League Against War and Fascism
American League for Peace and Democracy
American National Labor Party
American National Socialist League
American National Socialist Party
American Nationalist Party
American Patriots, Inc.
American Peace Crusade
American Peace Mobilization
American Poles for Peace
American Polish Labor Council
American Polish League
American Rescue Ship Mission (a project of the United American
Spanish Aid Committee)
American-Russian Fraternal Society
American Russian Institute, New York, also known as the Ameri-
can Russian Institute for Cultural Relations with the Soviet
Union
American Russian Institute, Philadelphia
American Russian Institute of San Francisco
American Russian Institute of Southern California, Los Angeles
American Slav Congress
American Women for Peace
American Youth Congress
American Youth for Democracy
Armenian Progressive League of America
Associated Klans of America
Association of Georgia Klans
Association of German Nationals (Reichsdeutsche Vereinigung)
Ausland-Organization der NSDAP, Overseas Branch of Nazi Party
Boston School for Marxist Studies, Boston, Massachusetts
Bridges-Robertson-Schmidt Defense Committee
Bulgarian American People's League of the United States of
America
California Emergency Defense Committee
California Labor School, Inc., 321 Divisadero Street, San Francisco,
California
Carpatho-Russian People's Society
Central Council of American Women of Croatian Descent, also
known as Central Council of American Croatian Women, Na-
tional Council of Croatian Women
Central Japanese Association (Beikoku Chuo Nipponjin Kai)
Central Japanese Association of Southern California
Central Organization of the German-American National Alliance
(Deutsche-Amerikanische Einheitsfront)
Cervantes Fraternal Society
China Welfare Appeal, Inc.
Chopin Cultural Center
Citizens Committee for Harry Bridges
Citizens Committee of the Upper West Side
Citizens Committee to Free Earl Browder
Citizens Emergency Defense Conference
Citizens Protective League
Civil Liberties Sponsoring Committee of Pittsburgh
Civil Rights Congress and its affiliated organizations, including:
Civil Rights Congress for Texas
Veterans Against Discrimination of Civil Rights Congress of
New York
Civil Rights Congress for Texas (see Civil Rights Congress)
Columbiana
Comite Coordinador Pro Republica Espanola
Comite Pro Derechos Civiles
(See Puerto Rican Comite Pro Libertades Civiles)
Committee for a Democratic Far Eastern Policy
Committee for Constitutional and Political Freedom
Committee for Nationalist Action
Committee for Peace and Brotherhood Festival in Philadelphia
Committee for the Defense of the Pittsburgh Six
Committee for the Negro in the Arts
Committee for the Protection of the Bill of Rights
Committee for World Youth Friendship and Cultural Exchange
Committee to Abolish Discrimination in Maryland
(See Congress Against Discrimination; Maryland Congress
Against Discrimination; Provisional Committee to Abolish
Discrimination in the State of Maryland)
Committee to Aid the Fighting South
Committee to Defend Marie Richardson
Committee to Defend the Rights and Freedom of Pittsburgh's
Political Prisoners
Committee to Uphold the Bill of Rights
Baltimore Forum Commonwealth College, Mena, Arkansas
Benjamin Davis Freedom Committee Communist Party, U. S. A., its subdivisions, subsidiaries, and
Black Dragon Society affiliates
FOR 444d USE PREVIOUS EDITIONS - 1 - (4)
1-58
 ppreved For Release
Communist Political Association, its subdivisions, subsidiaries,
and affiliates, including:
Alabama People's Educational Association
Florida Press and Educational League
Oklahoma League for Political Education
People's Educational and Press Association of Texas
Virginia League for People's Education
Congress Against Discrimination
(See Committee to Abolish Discrimination in Maryland)
Congress of American Revolutionary Writers
Congress of American Women
Congress of the Unemployed
Connecticut Committee to Aid Victims of the Smith Act
Connecticut State Youth Conference
Council for Jobs, Relief and Housing
Council for Pan-American Democracy
Council of Greek Americans
Council on African Affairs
Croatian Benevolent Fraternity
Dal Nippon Butoku Kai (Military Virtue Society of Japan or Mili-
tary Art Society of Japan)
Daily Worker Press Club
Daniels Defense Committee
Dante Alighieri Society (between 1935 and 1940)
Dennis Defense Committee
Detroit Youth Assembly
East Bay Peace Committee
Elsinore Progressive League
Emergency Conference to Save Spanish Refugees (founding body
of the North American Spanish Aid Committee)
Everybody's Committee to Outlaw War
Families of the Baltimore Smith Act Victims
Families of the Smith Act Victims
Federation of Italian War Veterans in the U. S. A., Inc. (Associa-
zione Nazlonale Combattenti Italians, Federazione degli Stati
Units d'America)
Finnish-American Mutual Aid Society
Florida Press and Educational League (see Communist Political
Association)
Frederick Douglass Educational Center
Freedom Stage, Inc.
Friends of the New Germany (Freunde des Neuen Deutschlands)
Friends of the Soviet Union
Garibaldi American Fraternal Society
George Washington Carver School, New York City
German-American Bund (Amerikadeutscher Volksbund)
German-American Republican League
German-American Vocational League (Deutsche-Amerikaniscfie
Berufsgemefnschaft)
Guardian Club
Harlem Trade Union Council
Hawaii Civil Liberties Committee
Helmusha Kai, also known as Nokubei Heleki Gimusha Kai, Zaibel
Nihonjin, Hefyaku Gimusha Kai, and Zaibel Heimusha Kai (Jap-
anese Residing in America Military Conscripts Association)
Hellenic-American Brotherhood
Hinode Kai (Imperial Japanese Reservists)
Hinomaru Kai (Rising Sun Flag Society - a group of Japanese
War Veterans)
Hokubel Zaigo Shoke Dan (North American Reserve Officers Asso-
ciation)
Hollywood Writers Mobilization for Defense
Hungarian-American Council for Democracy
Hungarian Brotherhood
Idaho Pension Union
Independent Party (Seattle, Washington)
(See Independent People's Party)
Independent People's Party
(See Independent Party)
Industrial Workers of the World
International Labor Defense
International Workers Order, its subdivisions, subsidiaries and
affiliates
Japanese Association of America
Japanese Overseas Central Society (Kaigai Dobo Chuo Kai)
Japanese Overseas Convention, Tokyo, Japan, 1940
Japanese Protective Association (Recruiting Organization)
Jefferson School of Social Science, New York City
Jewish Culture Society
Jewish People's Committee
Jewish People's Fraternal Order
Jikyoku linkal (The Committee for the Crisis)
Johnson-Forest Group
(See Johnsonites)
Johnsonites
(See Johnson-Forest Group)
Joint Anti-Fascist Refugee Committee
Joint Council of Progressive Italian-Americans, Inc.
Joseph Wedemeyer School of Social Science, St. Louis, Missouri
Kibel Seinen Kai (Association of U. S. Citizens of Japanese An-
cestry who have returned to America after studying in Japan)
Knights of the White Camellia
Ku Klux Klan
Kyffhaeuser, also known as Kyffhaeuser League (Kyffhaeuser
Bund), Kyffhaeuser Fellowship (Kyffhaeuser Kameradschaft)
Kyffhaeuser War Relief (Kyffhaeuser Krlegshilfswerk)
Labor Council for Negro Rights
Labor Research Association, Inc.
Labor Youth League
League for Common Sense
League of American Writers
Lictor Society (Italian Black Shirts)
Macedonian-American People's League
Mario Morgantini Circle
Maritime Labor Committee to Defend Al Lannon
Maryland Congress Against Discrimination
(See Committee to Abolish Discrimination in Maryland)
Massachusetts Committee for the Bill of Rights
Massachusetts Minute Women for Peace (not connected with the
Minute Women of the U. S. A., Inc.)
Maurice Braverman Defense Committee
Michigan Civil Rights Federation
Michigan Council for Peace
Michigan School of Social Science
Nanka Teikoku Gunyudan (Imperial Military Friends Group or
Southern California War Veterans)
National Association of Mexican Americans (also known as Asocia-
cion National Mexico-Americana)
National Blue Star Mothers of America (not to be confused with
the Blue Star Mothers of America organized in February 1942)
National Committee for Freedom of the Press
National Committee for the Defense of Political Prisoners
National Committee to Win Amnesty for Smith Act Victims
National Committee to Win the Peace
National Conference on American Policy in China and the Far East
(a Conference called by the Committee for a Democratic Per
Eastern Policy)
National Council of Americans of Croatian Descent
National Council of American-Soviet Friendship
National Federation for Constitutional Liberties
National Labor Conference for Peace
National Negro Congress
National Negro Labor Council
Nationalist Action League
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 Approved For" (ease 2002/01/08 : CIA-RDP79-0063200100070010-2
Nationalist Party of Puerto Rico
Nature Friends of America (since 1935)
Negro Labor. Victory Committee
New Committee for Publications
Nichibei Kogyo Kaisha (The Great FuitI Theatre)
North American Committee to Aid Spanish Democracy
North American Spanish Aid Committee
North Philadelphia Forum
Northwest Japanese Association
Ohio School of Social Sciences
Oklahoma committee to Defend Political Prisoners
Oklahoma League for Political Education (see Communist Politi-
cal Association)
Original Southern Klans, Incorporated
Pacific Northwest Labor School, Seattle, Washington
Palo Alto Peace Club
Partido del Pueblo of Panama (operating in the Canal Zone)
Peace Information Center
Peace Movement of Ethiopia
People's Drama, Inc.
People's Educational and Press Association of Texas (see commu-
nist Political Association)
People's Educational Association (incorporated under name Los
Angeles Educational Association, Inc.), also known as People's
Educational Center, People's University, People's School
People's Institute of Applied Religion
Peoples Programs (Seattle, Washington)
People's Radio Foundation, Inc.
People's Rights Party
Philadelphia Labor Committee for Negro Rights
Philadelphia School of Social Science and Art
Photo League (New York City)
Pittsburgh Arts Club
Political Prisoners' Welfare Committee
Polonla Society of the IWO
Progressive German-Americans, also known as Progressive Ger-
man-Americans of Chicago
Proletarian Party of America
Protestant War Veterans of the United States, Inc.
Provisional Committee of Citizens for Peace, Southwest Area
Provisional Committee on Latin American Affairs
Provisional Committee to Abolish Discrimination In the State of
Maryland
(See Committee to Abolish Discrimination in Maryland)
Puerto Rican Comite Pro Libertades Civiles (CLC)
(See Comite Pro Derechos Olviles)
Puertorriquenos Unidos (Puerto Ricans United)
Quad City Committee for Peace
Queensbridge Tenants League
Revolutionary Workers League
Romanian-American Fraternal Society
Russian American Society, Inc.
Sakura Kai (Patriotic Society, or Cherry Association - composed
of veterans of Russo-Japanese War)
Samuel Adams School, Boston, Massachusetts
Santa Barbara Peace Forum
Schappes Defense Committee
Schneiderman-Darcy Defense Committee
School of Jewish Studies, New York City
Seattle Labor School, Seattle, Washington
Serbian-American Fraternal Society
Serbian Vidovdan Council
Shinto Temples (limited to State Shinto abolished In 1945)
Silver Shirt Legion of America
Slavic Council of Southern California
Slovak Workers Society
Slovenian-American National Council
Socialist Workers Party, including American Committee for Euro-
pean Workers' Relief
Sokoku Kai (Fatherland Society)
Southern Negro Youth Congress
Suiko Sha (Reserve Officers Association, Los Angeles)
Syracuse Women for Peace
Tom Paine School of Social Science, Philadelphia, Pennsylvania
Tom Paine School of WestchQQster, New York
Trade Union Committee for Peace
(See Trade Unionists for Peace)
Trade Unionists for Peace
(See Trade Unionists for Peace)
Tri-State Negro Trade Union Council
Ukrainian-American Fraternal Union
Union of American Croatians
Union of New York Veterans
United American Spanish Aid Committee
United Committee of Jewish Societies and Landsmanschaft Fed-
erations, also known as Coordination Committee of Jewish
Landsmanschaften and Fraternal Organizations
United Committee of South Slavic Americans
United Defense Council of Southern California
United Harlem Tenants and Consumers Organization
United May Day Committee
United Negro and Allied Veterans of America
Veterans Against Discrimination of Civil Rights Congress of New
York (see Civil Rights Congress)
Veterans of the Abraham Lincoln Brigade
Virginia League for People's Education (see Communist Political
Association)
Voice of Freedom Committee
Walt Whitman School of Social Science, Newark, New Jersey
Washington Bookshop Association
Washington Committee for Democratic Action
Washington Committee to Defend the Bill of Rights
Washington Commonwealth Federation
Washington Pension Union
Wisconsin Conference on Social Legislation
Workers Alliance (since April 1936)
Yiddisher Kultur Farband
Young Communist League
Yugoslav-American Cooperative Home, Inc.
Yugoslav Seamen's Club, Inc.
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 Approved For Release 2002/01/08 : CIA-RDP79-00632A000100070010-2
CERTIFICATION
I certify that I have read the names of the above listed organizations.
To the best of my knowledge and belief, I am not, nor have I been a member of, contributed to, received liter-
ature from, signed petitions of or in behalf of, or attended meetings of any organization listed above, or any
organization outside the United States espousing Communist, Fascist, Totalitarian or Nazi causes, except as noted
below.
To the best of my knowledge and belief, none of my close relatives are, nor have ever been members of, con-
tributed to, received literature from, signed petitions of or in behalf of, or attended meetings of any such organiza-
tions, except as noted below.
INSTRUCTIONS
For the purpose of this certification, if an applicant or employee is completing this form, the term "close rela-
tive" will include spouse, children, parents, brothers, sisters, uncles, and aunts. "Close relatives" of the spouse, for
this purpose, will include children, parents, brothers, sisters, uncles, and aunts.
If there are exceptions to this certification, set forth below under Remarks all pertinent information concern-
ing the nature and extent of your activities or those of your close relatives in such organizations, including the
names of the organizations, dates of membership, meetings attended, titles of positions held, amounts and dates
of contributions, nature of petitions signed falling within the meaning of the above certification and circumstances
thereof, titles and authors of literature received, and dates on which received.
In exceptions concerning relatives, include only such information presently known to you or available from
your own records.
If necessary, use additional sheets and sign each sheet. Write none if there are no exceptions.
REMARKS: To be completed by Spouse
REMARKS: To be completed by Applicant or Employee
Date
Date
Signature of Spouse
Signature of Applicant or Employee
Address - City and State
Address -City and State
Witness
Witness
Address - City and State Address - City and State
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-Moe -me
 0010-2
MEDICAL RECORD To be comple a by applican
HEIGHT
2 ADDRESS
1. NAME
3. SEX
4. MARITAL STATUS
5. DATE OF BIRTH
6. NO. OF CHILDREN
WEIGHT
MEDICAL HISTORY
6. CHECK BELOW IF YOU HAVE EVER HAD ANY OF THE FOLLOWING. EXPLAIN ALL CHECK MARKS ON REVERSE SIDE. IF NONE CHECK HERE
EPILEPSY 8 - BL00DSPITTING 15 -VARICOSE VEINS 22 - FAINTING SPELLS 29 -CANCER OR TUMORS 36 -FREQUENT SORE THROAT
1
_
ARTHRITIS 9 _ POLIOMYELITIS 16 -SWOLLEN GLANDS 23 - RECTAL TROUBLE 30 _FREQUENT INDIGESTION 37 _ CHOREA (ST. VITUS DANCE)
2
_
DIABETES 10 -TUBERCULOSIS 17 -TYPHOID FEVER 24 - RHEUMATIC FEVER 31 -PEPTIC (STOMACH) ULCER 38 _DERMATITIS (SKINTROUBLE)
3
_
DISCHARGE (EAR) 18 -HEART TROUBLE 25 _ KIDNEY TROUBLE 32 _BACKACHE OR SPRAIN 39 _FREQUENT NOSEBLEED ING
4 PARALYSIS 1I
-
CHRONIC COUGH 26 - VENEREAL DISEASE 33 _ ASTHMA OR HAYFEVER 40 _FREQUENT HEADACHES OR
EARACHES 19
JAUNDICE 12
5
_
_
_
DIZZINESS
6 MALARIA 13 _ PLEURISY 20 _ HERNIA (RUPTURE) 27 - SHORTNESS OF BREATH 34 _ DIFFICULTYOFURINATION 41 _ NERVOUS OR MENTAL
7 GOUT 14 - PNEUMONIA 21 -FREQUENT COLDS 28 - CHRONIC CONSTIPATION 35 _ HIGH BLOOD PRESSURE BREAKDOWN
6A. ILLNESSES NOT LISTED ABOVE
6B. DISEASES OF CHILDHOOD
7. GIVE DETAILS OF ILLNESS. OPERATIONS (Include tonsils), INJURIES (Include fractures)
YOU ANY IMPAIRMENT OF SIGHT OR
9. HAS YOUR WEIGHT CHANGED IN LAST TWO
10. MENSTRUAL HISTORY (Include date of
8. HAVE
last period)
HEARING
YEARS
^ INCREASED ^ DECREASED
HOW MUCH LBS
11. HAVE YOU BEEN VACCINATED FOR SMALLPOX
12. WHAT OTHER VACCINATIONS OR INOCULATIONS
13. HAVE YOU EVER USED ALCOHOLIC OR MALT
HAVE YOU HAD
LIQUORS TO EXCESS
^YES ^NO DATE
HAVE YOU EVER RECEIVED TREATMENT FOR
14
15. WHEN DID YOU LAST CONSULT A PHYSICIAN (Give name
16. DO YOU SMOKE (If so
.
ALCOHOL OR DRUG HABIT
of physician and date)
how much)
17. MILITARY SERVICE
I. YEARS OF SERVICE 2. BRANCH OF SERVICE 3. DATE OF DISCHARGE
5. ARE YOU APPLYING FOR OR RECEIVING ANY GOVERNMENT PENSION
4. REASON FOR DISCHARGE
OR DISABILITY PAYMENTS 5A. IF SO, WHAT PERCENTAGE OF DISABILITY
6. PRESENT DRAFT MEDICAL STATUS 7. IF 4F, FOR WHAT REASON
18. HAVE YOU EVER BEEN REFUSED INSURANCE
19. HAVE YOU ANY COMPENSATION CLAIM PENDING
20. FAMILY RECORD AND MEDICAL HISTORY
FAMILY
LIVING
AGE
HAS ANY MEMBER OF YOUR FAMILY EVER HAD:
(Include
AGE
qq
(S t at
f
Y
DECEASED
(Cause)
AT DEATH
DISEASE
YES
NO
MEMBER OF FAMILY
siblings)
h)
heal
TUBERCULOSIS
FATHER
CANCER
MOTHER
INSANITY
HUSBAND
EPILEPSY
WIFE
DIABETES
APOPLEXY(Stroke)
HEART TROUBLE
KIDNEY TROUBLE
UREUD
RES
P
S
I certify that the foregoing statements are true to the best of my knowledge and belief. I understand that
leaving out or misrepresenting facts called for above may be the cause for refusal of employment or separa-
tion from the organization.
I hereby grant permission to the examining physician to disclose any and all information herein or herein-
after furnished by me to the organization as may be deemed necessary.
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DATE SIGNATURE OF APPLICANT
 Approved For Release 2002/01/08 : CIA-RDP79-00632A000100070010-2
OFFICE OF MEDICAL SERVICES
PRIVILEGED MEDICAL INFORMATION
THIS ENVELOPE NOT TO BE USED FOR MAILING PURPOSES
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