GRILL FLAME VOLUNTEER CONSENT STATEMENT (ANN E. DJUPMAN)

• Document Type: CREST
• Collection: STARGATE
• Document Number (FOIA) /ESDN (CREST): CIA-RDP96-00789R002100150020-1
• Release Decision: RIPPUB
• Original Classification: S
• Document Page Count: 2
• Document Creation Date: November 4, 2016
• Document Release Date: December 4, 1998
• Sequence Number: 20
• Content Type: CONT

Approved For Release 2004/03/D7 : CiA-RDP96-00789R002100150020-1
GRILL FLAME VOLUNTEER CONSENT STATEMENT SGFOIA3
I A,yti E ap,114/4 5 a
NAME SEMEN-
volunteer for INSCOM Project Grill Flame. I understand this program involves
training designed to enhance inherent psychic abilities. I consent to this
training and willingly volunteer to participate in INSCOM intelligence
projects using my psychic abilities. I understand this program deals with
mental perceptive abilities beyond the range of the five corporal senses
and for this reason an aspect of mental training is involved. I understand
that the purpose of this training is to teach me how to discipline my
mental perceptive abilities and focus them on data beyond the range of the
five corporal senses.
I understand that as a volunteer I may withdraw from the program at
any time for any reason. My decision to withdraw from the program will be
accepted without controversy.
I understand that for precautionary and screening reasons that I as
a GRILL FLAME volunteer must have a Class A physical exam to include a
stress EKG prior to beginning training.
NOTE: Physical examination taken within the past 12 months is acceptable.
WITNESS VOLUNTEER
Approved For Releas k-Zd(1/Q,Q`` : CIA-RDP96-00789R002100150020-1
 Approved For Release 2001/03/07 : CIA-RDP96-00789R002100150020-1
DATA REQUIRED BY THE PRIVACY ACT OF 1974
(5 U.S.C. 552a)
1. Authority : National Records Art, )14 U . S . C . 3102; E. 0. 9397, Numbering;
System for Federal Accounts Relating to Individual Persons, November 22, 1.9113.
2. Principal Purpose: To maintain a record of those individuals who have
or have had access to GRILL' FLAKE information through the use of their name
and/or Social Security Number.
3. Routine Uses: The Social Security Number is to be used to identify the
individual, and. the information is to be retained strictly within the Program.
1+. Mandatory or Voluntary Disclosure: Information is disclosed on a
voluntary basis, but withholding information will render it impossible to
grant an individual access to or participation in the Program.
Approved For Release 2001/03/07 : CIA-RDP96-00789R002100150020-1