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| 26s. REFERENCES, (Name three persons, not relatives or employers, who are aware of your qualifications « 2 tie RAMEINFUUL SoS 50° HOME ADDRESS. + + civegt BUSINESS ADDRESS Nat S. Rogers eomes=” Holly Lanes Mercer Isi,- Wash ,Cong, Paul N. McClosky, <> ; one es Jr. House of Rep-... =" resehtatives "02> Bes 2BNcLosWaTER LS AMAdM am eame three persona, such as friends, sch Hose Ruilgdin es 889 sheen Wash 8 yr 6 wA, Wesley Hodge. 2... 0p se. - 1700 Norton Bidg. : ey Ca Paging % “-- Seattle, Washington House of Representatives Jack E, Hullin & a eer DeanG. Ostrum” _., c/o Ohio Bell Telephone, Cleveland, Ohio _ 27, TO YOUR KNOWLEDGE, HAVE YOU EVER BEEN THE SUBJECT OF A FULL FIELD OR BACKGROUND PERSONAL INVESTIGATION BY A FEDERAL GovERNMENT? [J ves GINO. Uf your answer ia Yes," show in item 28,,(1) the name of fhe investigating agency (2) the approximate date of investigation, and (3) the level of security clearance granted, if. known.) : 2B, SPACE FOR CONTINUING ANSWERS TO OTHER QUESTIONS. (Show item numbers to which anawors apply. Attach a separate sheet if there fe not enough apace here.) Before signing this form check back overt it to make sure you have answeted all questions fully and correctly. Le Os so . CERTIFIC ‘ aT eR I Curtiry that the statements made by me on this form ate x s: C knowledge and | Ezg belief, and are made in good faith, 1s punishable by law. , (OA : _— SIGNATURE—Sigr original and firet carbon copy) . ; INFORMATION TO BE FURNISHEOIBY AGENCY : INSTRUCTIONS TO AGENCY: See Federal Personnel Manyat Fhapter 736 and FPM Supplement 296-31, Appendix A, for details on when this form is required and how it is used. _If this is # request for investigation before appointment, insert “APPL” in the - space for Date of Appointment and show information about the proposed appointmenc in the other spaces for appointment data. he original and the first carbon cépy should be signed by the applicant of appointee. Submit the original and the uusigned carbon copy. of the form, Standard Form 87 (Fingerprint Chart), and any investigative information about the person received on voucher forms or otherwise, to the United States Civil Service Commission, Bureau of Personnel lovestigations, Washington, D.C, 20415. If this is a request for full field security investigation, submit these forms to the at:ention of the Division of Reimbursable In- vestigations; if this is a request for preappointment nationa} agency checks, submit these forms to the attention of the Control Section. RETAIN THE CARBON COPY OF STANDARD FORM 0% (SIGNED BY THE APPLICANT OR APPOINTEE) FOR YOUR FILES x .- ‘| DD comperitive. (Unctude indefinite ‘and tem- porary types of competitive appointments.) DEPARTMENT OR AGENCY ..-. : DUTY STATION eet SEND RESULTS OF PREAPPOINTMENT CHECK TO: ee « " e x Tae Is A SEnsitive Position . * ~ GSIGRATURE AND TITLE OF AUTHORIZED An. SCY OFFICIAL)