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s ———___B_} perm ABC-1 - UNITED STATES . (3-54) Form approved ATOMIC ENERGY -GOMMISSION ____._ Budget Bureau No 28-R0016 | WASHINGTON, D. ¢ — (Expires Sept. 30,1955) nm : com spbtaurze > of . SORMEL SECURITY QUESTIONNAIRE (=) ny Pees ara) INSTRUCTIONS —AN sections must be completed Write “None”. ‘when a pheable Type or pnnt all answers. If space 1s not eqaate for complete aLSWeTA, fuse the additional space provided under item No 27 All addresses must show street num- ber, streefteity, and State ! Be tt NAME (Lats, fret, mcldle) . ‘ 5 DESCRIPTION (Check which) [] MALE [_] FEMALE DB ‘tan, ~ WA £02102" - peg ime | eer COLOR EYES | COLOR HAIR oa caste aan 5 (Chak whet) 7 BIRTH DATE gem QO prvorceD ¥ 4 warricol_) wipowtER) ‘ 4. ALL OTHER ADDRESSES FOR PAST 15 YEARS DATE : 1 FKetes a OF 1/20/sh, to 3/15/56, CITIZENSHIP U's CHALIEN Si be? IF WS CITIZEN, INDICATE WHETHER eake : aaice Ave. Ln EA to 7/20/ vero OF fe ev itiuthasearion ‘Tashtngton, De ee Ore beta DATE 1G Sur a 7“ ee ————— IF ALIEN, a ALIEN REGISTRATION [PAE ‘ fork Us-ponu & Ipc Ay DATE OF ENTRY - PORT OF ENTRY at rr 10. DRAFT BOARD NUMBER AND ADDRESS WITH WHICH REGISTERED af 1 SATL keger rue) _ ob Wyle oe va gard ' a a see 7 Mes S22 pool < a Cuts - Une. eo y-a m v at . 7 o£ the ot, Ce gg Mee TE wa te stag) 7 ‘ 2 PAD ILS gt et TD LPTGA- . Uitte ¢t trove rr Cm tre oem On wu 7 ‘ Washington, D. C. Washington, D. 6. RECORDED - 7" myase a leo as Page 1 et ee ee