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ZU MAVE YOU EVER SLEW ARRESTET, CHARCED, OR HELO OT FEDERAL, STATE, OM OTHER LAW ENFORCEMENT AUTHORITIES, FOR ANY VIOLATION OF ANY FEORRAL LAW, STATE LAW, COUNTY OR MUNICIPAL LAW, REGULATION OR ORDINANCE? iwCLUSCE ALL + COURT MARTIALS, BHILE IN MILITARY SERVICE. OO NOT INCLUDE AMYIHING THAT HAPPENED BEFORE YOUR.IETH BIRTKOAY. 00 NOT INCLUDE TRAFFIC VIOLATIONS FOR WHICH YE ONLY PEMACTY IMPOSED WAS A'FINE OF-S2E.00 OR LESS TALL OTMEN CHARGES MUST BE INCLYCED EVEN IF THEY WERE CisMISSED. ' as) ves (Bx0 tPF VES", GIVE CATE AND PLACE, CHARGE, AND DISPOSITION: | a ' eT 2 - i! hee ce ie a or i . . erm 30. HAVE YOU EVER SEEN PREVIOUSLY GRANTED OR DENIED A SECURITY & GRANTED bh DENIED CLEARANCE BY TKE OEPARYWERT OF TKE ARMY, WAVY, OR ain FORCE, 8Y Ove - Pwo (Ores ar.iF “ves, INCICATE WHEN CRANTZD, THERE, AND BY BHOM TF CENIED, WHEM AND BY WHOM] 32. BHAT WAS THE LEVEL OF THE . CLEARAWCET ‘ REFERENCES (Oire ttre perecnal relerances, stating bueiriese address of all references, it known. Do net intivde reftativen former employ ert, ” of petadna Siting outside the United Stace.) a4, BIT ALL FOREIGHM OWNED CORPORATIONS OR OTHER BUSINESS ORGANIZATIONS IN WHICH YOU ARE AN OFFICER, DIRECTOR, . OMNER, OR ACT IN A REPRESENTATEVE CAaPActTy, (Ii none, ao indicete), ; . xe 7 14a uel - OF Yy “tbe at . beet Ree es eee A 4 ” . 1 ” . Boxy ey RB ha Qe ov ee or FEAT . sie Me 2 rs oe terete aya! rey ss * tre -tagt bE UPS ot he wwe Om mse 8, bot tee whl tod, ge eMab ogy a at WARNING: Read every 34 be ‘cert? that 1 koow that ‘say nisrepreséntetton‘te fates winds AR Read eel: seigtpce ot Cenifietion tore Sante * id ment” made by ‘ceherein nay dibject vie to prosecution texter t certify that the gsteian inede by aa above.sre true, couplets... .}- Sectton Tol ofthe United States Criminal Coder with peaahien i rade in good fain" PEr> "eee kre aes te a, re nee. up to five ($) years imprisonment and $10,000 fine. I certify that [aia kRlzen of the: Dated States”... CIUCUL. Detgy hess F dav syed ent a understand 96 tach sentence of this ge ess ebro ee batt FY Ste ep eA wt ot ~ a. Ae mm F * “8 ommee ~] n; ie) + ir oy Rtya SP 4a ar a, A fot, eS vag ha aw + vote = Ae NY othe “a TINT oe ry