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V9. HAVE YOU EVER HAD A NERVQUS BREAKDOWN fydur answer r fo “Yoo” wed Getaile ia iten. “COUNTRY San El Salvador & & Mexico Canada * x - Belgium, Hollang, Den- 5/66 ~ mark, | Sweden, We ermany, wi 2. ARE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF ANY FOREIGN OR DOMESTIC ORGANIZATION, ASSOCIATION, MOVEMENT. GROUP, OR COMBINATION OF PERSONS WHICH IS TOTALITARIAN, FASCIST. COMMUNIST, OR SUBVERSIVE, OR WHICH HAS ADOPTED. OR SHOWS, A POLICY OF ADVOCATING OR APPROVING. THE] 5... IN TATES, OR WHICH SEEKS ~ COMMISSION OF ACTS OF FORCE OR VIOLENCE TO DENY OTHER PERSONS THEIR RcHTS SUNDER THE CORSELTUTION OF THE U yo ALTER THE FORM OF: GOVERNMENT OF THE UNITED STATES BY UNCONSTITUTIONAL L EANS!.. Oy ves & NO. 23. IF YOUR ANSWER TO QUESTION 21 RF 2 b ABOVE 1S “YES,” STATE THE NAMES OF ALL SUCH ORGANIZATIONS, ASSOCIATIONS, MOVEMENTS, GROUPS, OR COM- BINATIONS OF PERSONS AND DATES OF MEMBERSHIP. IN [TEM 28 OR ON A SEPARATE SHEET TO BE ATTAC-iCD TO AND MADE. “APART OF THIS FORM, GIVE CcOM- PLETE DETAILS OF YOUR ACTIVITIES THEREIN AND MAKE ANY. EXPLANATION You DESIRE REGARDING YOuR MEMBERSHIP OR acriviTl ES. -2 >. NAMEINFULL | 5 an Dee tes rete TQ. eek’ OFFICE HELD ~~ a, MEMBERSHIP IN OTHER ORGANIZATIONS. (Liat alf organizations in which you are now a member or have been a member, except ¢ those which show religious or political affiliations.) (If none, so state.) ; NAMEINFULL ADDRESS “Sl type FROM tro! ‘OFFICE HELD Rainier Club - Seattle, Wash. | Social 7 1964 Date || Harbor Club an Seattle, WwW ash. Social oe 1964. “Date Kappa Sigma — Seattle, Wash. Fraternity 1943 Date _ 25. RELATIVES. (Parents, epouse, divorced apoyee, children, brothers, and sisters, living: ot dead. Namie of spouse should include maiden ‘name and any other names by previous marriage. If person is dead, state ‘dead’ after relationship and furnish information for other columns as of time of death.) : fee dee BED pee “, . . YEARROF RS COUNTRY OF = PRESENT ‘RELATION NAME IN FULL BIRTH “ADDRESS oa CITIZENSHIP Father (dead) Rudolph... 1904 | 202 San Vicente - oe - °°" Santa Monica; Cal. TALS AUR Mother. _——iLillianC. = ~—.1910 6052 Colgate ~ ; Ao y. USA, Se _ Los Angeles, Cal... Wife. JeanneE. .° 1927 330 Chesapeake Dr, _ Ta USA ee ce rs . Great Falls, Va." a Son. ~-- . Peter S..-- | 19505 see ge aan map: USA. Daughter * “JanC. 7 1952... ot MO re = a USA - Son - i: ° ThomasJ. .- 1954. => EM eet USA Daughter - Jody Ann -— 1956 a poo Son ¢ . RobertP. 1959