STATEMENT OF CONSENT (FORMS) BLANK

• Document Type: CREST
• Collection: STARGATE
• Document Number (FOIA) /ESDN (CREST): CIA-RDP96-00789R002600160009-8
• Release Decision: RIFPUB
• Original Classification: U
• Document Page Count: 2
• Document Creation Date: November 4, 2016
• Document Release Date: December 4, 1998
• Sequence Number: 9
• Content Type: CONT

Approved For Release 2000/08/08 : CIA-RDP96-00789R002600160009-8
STATEMENT OF CONSENT
INSCOM CENTER LANE PROJECT PARTICIPANT
IAGPA-F-SD Date:
1. (S/CL-4/NOFORN) I, voluntarily accept assignment
to the INSCOM CENTER LANE PROJECT ICLP and fully understand that:
a. (S/CL-1/NOFORN)) The Army General Counsel has determined that ICLP
constitutes experimentation on human subjects. As required by Procedure 13 of DoD
Directive 5240.1-R, approval for project activities has been granted by Secretary
of the Army.
b. (S/CL-3/NOFORN) The aim of ICLP is to develop highly skilled personnel who
are capable of conducting professional level intelligence/counterintelligence
operations through use of psychoenergetic methodology. Development of ICLP
personnel will be accomplished with special training based on mission requirements.
c. (C/NOFORN) Assignments in ICLP are governed by the sensitivity and degree
of expertise required for the position. I will be assigned in accordance with my
capabilities and experience, regardless of my rank or previous position. Due to
the nature of training involved, the duration of my participation is indefinite.
Records of my involvement will be available to project personnel, but otherwise
protected under project security measures.
d. (C/NOFORN) The primary consideration in any career development or
assignment action will be ICLP mission and operational requirements. I understand
that exemption, interruption, or delay in normal career development patterns--such
as branch schooling and assignment opportunities- -may prejudice future promotion
and-assignment potential. I have been assured, however, that every effort will be
made to preclude the adverse effects listed above on my career.
2. (S/CL-3/NOFORN) PSYCHOENERGETICS (PE) include various processes by which
individuals psychically interact with objects, locations, and organisms.
a. (S/CL-1/NOFORN) I understand that while there is no demonstrated risk of
permanent or temporary injury (including physical, psychological and/or damage to
participants' reputation) to project personnel beyond risks to which they would
ordinarily be exposed in their daily lives, the potential for injury during some
training cannot be conclusively ruled out.
WARNING NOTICE:
CENTER LANE SPECIAL ACCESS PROGRAM
RESTRICT DISSEMINATION TO THOSE WITH VERIFIED ACCESS
CATEGORY CL-4
NOT RELEASEABLE TO FOREIGN NATIONALS
CLASSIFIED BY: CDR, INSCOM
DECL: OADR
Approved For Release 2000/08/08 : CIA-RDP96-00789R002600160009-8
 Approved For Release 2000/08/08 : CIA-RDP96-00789R002600160009-8
b. (S/CL-1/NOFORN) I may temporarily choose not to perform PE at specific
times, or permanently discontinue participation without prejudicial effect.
Termination will be affected by notifying the ICLP Manager or in his absence, his
designated acting ICLP Manager.
3. (S/CL-3/NOFORN) As a participant in ICLP, and IAW AR 381-17, I consent to tape
recording, monitoring and transcribing of all operational and training interviews
in which I am involved as an integral part of the ICLP mission. I understand that
these recordings are subject to being monitored and/or transcribed by third parties
not otherwise involved in operations or training. I waive any claim or right of
ownership to all tape recordings and transcripts made in conjunction with ICLP,
with the understanding that these tape recordings and transcripts are property of
the United States Government.
4. (S/CL-3/NOFORN) I further consent to participate in any nonintrusive
biomonitoring activities that are necessary for project mission accomplishment.
5. (U) I hereby acknowledge receiving formal counseling concerning my assignment
to ICLP. Basic operational and training procedures (both routine and experimental)
and their purposes, as well as attendant discomforts, risks, and benefits have been
explained to me. I understand that I may at any time ask questions of project
personnel relating to areas unclear to me. I further understand that my
participation in ICLP is voluntary and that at my request I may at any time be
reassigned without fear of adverse personnel action.
Signature: Signature:
me, Rank/Grade o itness Name, Rank/Grade ot Part cipant
Social Security Number Social Security Number
it rganization i rganization
Position Position
Approved For Release 2000/08/08 : CIA-RDP96-00789R002600160009-8