◆ SpookStack

e ‘ . ° . (. . 1. aw en a | CASESERIAC NO. (CSC use only) We ee ¢ @eunrry ivestieation pftan Craacceartt 5 oY FOR SENSITIVE POSITION INSTRUCTIONS.—-Preparein triplicate, using a typewriter, Fillinallitems. If the answer is “No’’ or None," so state. If more space is needed for any item, continue under item 28. ‘ [ 1. FULL NAME TNAM ¥, Mx 2, DATE OF S1RTH Unitiels and ebridgementa of full name are not acceptable. Il no olddle b6 Per BOC b7C Per BOC OTHER NAMES USED. (Maiden name, nemes by former matriafes, former names changed PLACE OF BIR legally of otherwise, aliaens, nicknames, ete. Spocily which, and show dates veed name, show "“(NMN)”; it initials only, show “(no given or middie namey’ | 4 LA MALE LJFEMALE $ HUGHT | WEGHT| COLOR | COLOR EYES FAIR 7O" | 200 BL Br } arena teh SP ieee aS AS OG ERECT I eed mma G& Per BOC’: 7, IF MARRIED, VEDOWED, OR DIVORCED, GIVE FULL NAME AND DATE AND PLACE OF BIRTH OF SPOUSE OR FORMER WIFE'S MAIDEN NAME. GIVE DATE AND PUACE OF MARRIAGE OR OLVORCE, t €. CHSINGLE (2) MARRIED ‘OC wivowery (2 prvorceo 8 DATES AND PLACES OF RESIDENCE, pS ectual places of residence differ from the mailing addresses, lucnish and identity both Bein with present and £0 back to January 1. 1997, Atinue under item 78 on other side if neocersary.) . srayO6 Per BOC b7C Per BOC FROM Io RUMBSER AND STREET cry 11/01/70 Present 07/68 10/70 05/68 07/68 09/67 04/68 11/66 09/67 04/66 11/66 04/65 04/66 03/65 04/65 01/64 03/65 11/63 01/64 11/60 12/63 10/60 12/60 ry fHisyeiam NATURALIZED ALIEN REGISTRATION NO, DATE, PLACE. AND COURT (us. cz = fos CERT, NO. ; PETITION NO. OERIVEO-PARENTS CERT, NOG), ALIEN REGISTRATION NO, NATIVE COUNTRY 10, EOUCATION. (AIL achoole above elementary.) t « . ‘ ett ~ . NAME OF SCHOOL, ADDRESS. .__ FROM CY, 13, THIS SPACE FOR FELUSE, (See also stem 29.9 13. MRITARY SERVICE (Past of present) ; ‘ b7C Per Boc ' SERAL NO, i : ‘ BRANCH OF SERVICE sid on eae. rating (Areny, Navy, Ait Force, ete.) FROM (Yr) roe BoC Marine Corps 1951} 1970 DB Cooper-/192 -