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ey STATEMEHT OF PERSONAL é HISTORY INSTRUCTIONS: Reac the certification at the end of thir questionnaire before entering the required date. Pring oe type all arawert, A! questions and itatements must be completed. Hf the answer is “Mone,” so state. Do not mizstate or omit material fact since the statements made herein ace subject to ver.fcation. Lf more space is needed, use the Remarks section, item 26, and attach additional sheets if necessary. The itformation entered hereon is for official use only and will be maintained in confidence. 4 (Pernt) FURST WAM IDOLE Meee MIDE MAME C77 ge -LAST NRE ve : z pn mas ata nf Lb sho ae we dye te BOACIAS( SE BSC RBAME (S$) OF CORRGES RAE (O¢her then by marriage} & FERMANCMT MAILING AGORESS __ LIAT SS RR ow % GAIT OF HATH (Dee, month, prac} : “react OF mani (Cetp, County, Stace, and Cevunrry} PLACE CORTFIRATE RECCROTD AQT Purr v) . PAY ee CALE OA Y Tow ease | Aki we LIGHT COLOR OF EYES woes i A ~ 6? fee eee Ga ea i & Geto RAS BS TOR SY Oe ite kL CRONE aS Dae Ce Bt l AYA Ye hide S8k TOU SOW OF KRAVE FOU EVER BEON abot Ire TO THE use OF HAT FosmIAS LD RAACOTIS OR Baha yRAs ES: LI ris is ARE YOU ROME CH HAL VOU EWOR BEEN & CHROMIC USLA TOT RCESS OF ALCOHOLIC BEVEMEGE S$? SASWER TO AW Y OF EMT SBC 1S eh) ALI a r rus : NAT owt + 48 MAT URAL CERT LATE HD Peearae. | ec he tee [ | as | 1 owe tre - ae, er Sh ee EM BEAGLE ATION Bei RATIVE COUNTAY ! | { r are . | it a ee ME IGeT 6 SUL AS ¥ES MO yee iF CE RIVEO PAROATS COMPIRICATE OS) DATE PLACE £90 COURT BO FOU INTE TO BECOME aU -S CiTiene AR VOR EME SER TE UA CTIN Cote WE TPE 5 AE FORTS ORANG FULL rae C) ves GRADE ANG St Bath AG | SER t ahi COMPONTAT DATE CURRENT aC TivE SERVICE STARTED DRGANIZA TION AND STATICH iM s, ee nee ld Te me ee cit ae ie nndinn = Efe CJ wo ores.” COMPLETE THE roLLOWwING PZ TRO APD STAT en OR WELT ARO LOCATION i AAT TOUR SE ATLY AOE MAT OF aS RESERV OR RATIONAL GURAOD ORGANIZE TION! CHALE 44D ELH. CE Pa SP AWICE AND COM PORE AY aps OE TOU PRE OO IUCLES IPED Th OF EULA ED AC THE COTY CHW ONG FULL OAY FROM WHICH TOU WERE OISCHARGED OR SEPARATED TO-Civiliat STATUS" Ki VES. 9 Pap I UVES COMM ETE THE POLL Om oN eave mt er a OO Eoesthe ee i USA 4. Mbek rts ___t eo . MARGLS OF SUPAMAT IONS TGAADE AAD SE RWOCE MC Ws Q-fe tes? EQUCATION (Account! for all civilian schools and military academics. _ eS MOMTH ARS TC AR SAME AND LOCATION OF SCHOOL Lert bc’ Etementy — fededl Chet ype ceos Se Aven IcAere FAMILY (Logt en order fiern, paresis, spouse, guardians, siepparents, foster parents, parents-in-few, fosmer apoune(s) (if divorced dive date and places children Arothedt and sestess, even though deceased include ang others you resided with af with ehom # close relationship garstedutccuts ff the perasnaenet a US citeren by berth, give date and port af entry, ahien registration Humber, natural sation certibcate AuMmber and glace of spguence 3 tr ee ee ee RELATION AND Maas FaqHt BATE AND PLACE OF RIK PRESENT ADDRESS. Living Exception to Standard Form 86 Approved by Burcau of the Budget July 1963