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TENT OF PARTICIPATION AN EXPL REGARDING MEMBERSHIP IN ANY OF THESE O ‘ATIONS MAY BE FURNISHED UNDER 21 IF YOUR ANSWER TO QUESTIONS 17, R20 IS“YES" STATE THE NAME OF THE ORGA ON, DATES OF MEMBEKSHIP, ANU EA- ITEM NO 27, IF YOU DESIRE TO EX THE CIRCUMSTANCES OF YOUR MEMBERSHIP NAME "=" ADDRESS =~ ———— FROM— TO OFFICE HELD G2 RELATIVES (Parents etepparancs faster parents spouse divorced spouse or spouses children brothers, susters, stapbro hers, atepsstors, halfbrothers halGstere father itow, and mother in lato, La or deo, Name of spouse should include madden name any other names by previous marrsage. In the evens of marriae suucyant to be exouton of this Quesnonnaire ull be necessary thes data concerning the new spouse be furnished on Form AEC 354 } RELATION NAME IN FULL | Ace | ADDRESS ather Béwin Freemont Ladd Deceased U.S.A. PRESENT CITSZEN- SHIP Mother nah Sprogle 90 | 8009 Barron St., Takoma Wife TT C™C™C™CSC—SS 52 | Geneva, Fla. Father-in-lew, David G. Peiffer Deceased Mother-in-law, Nel) Gross Preiffer Brother [| Sh ‘Brother ase or a é 23 REFERENCES (Nome three persons novrelaives or employers whe ire well EPROPS LIPID NAME 1 AOBRCSS j TEARS KNGAT ne IOLATIONS)? . Paes . . Yes’ or No Aasiwer “Ye. Ne IF YOUR ANSWER 1S* YES" LIST ALL SUCH CASES IN ITEM 25_ IN EACH CASE GIVE (1) THE CHARGE OR NATURE OF THE OFFENSE (2) THE DATE, (3) THE PLACE WHERE ARRESTED, (4) DISPOSITION OR PENALTY POSED. VP ANY ¢ ‘ 25 ARRESTS (Include alt arresis and fines other than mmor traffic violanons) CHARGE PLACE WHERE ARRESTED DISPOSITION None Zo PREVIOUS SECURITY CLEARANCE A TO YOUR KNOWLEDGE HAVE YOU EVER BEEN INVESTIGATED BY ANY BRANCH OF THE FEDERAL GOVERNMENT? . s ae oe . B TO YOUR KNOWLEDGE HAVE YOU EVER BEEN REFUSED CLEARANCE BY ANY BRANCH OF THE Answet~ ‘No FEDERAL GOVERNMENT? are grararar rarer ararararan 1 : IF YOUR ANSWER TO EITHER QUESTION A OR B IS YES, PLEASE FURNISH DETAILS RO answer fax ar No CERTIFICATION san 7 Ag (o) 4 7 2 co ry ww ba (2) Zz ay = 4 i=] ms m <= 2G TF = mm i~s lt =z oy C uy a fo) ey [2] ] oY TO BE FILLED OUT BY AGENCY OR FIRM EMPLO YING _ BRIEF DESCRIPTION OF DUTIES (Description should not reveal classsfied information) NAME OF AGENCY OR FIRM ADDRESS WILL PERSON HAVE ACCESS TO RESTRICTCD DATA? CI yes (J No WILL PERSON HAVE ACCESS TO AN EXCLUSION AREA? [) yes [) No TT en a ne ee oe. (Check the ons black appiicable} [1 sriecneo ee OF F BI FINGERPRINT en (SIGNATURE AND TITLE OF OFFICIAL REQUESTING CLEARANCE) (1) 1-4 ATTACHED FILE CRECK) Page 3 (] Fincerrrent carp ATTACHED ==