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ar, 4 . . . al : : 22, RELATIVES (Perens, ssepporents, foster parents, tpoust, divorced spouse or 4 , children, brothers, sisters, seepbroskers, stapsistars, Ralftrethers, halfeisters, father-in-iau? ‘and mother i: u r in-dgio, Ti or Nama of spouse should include maiden name and any other names by evious marriage. in the evans of marriage subsequent i the execution of this Questionnaire, ie oil be necessary thas dole concerning the nave tpoase be furniohed ca Fore MECISES i 23. REFERENCES (Name shree persons, mit relative: or employers, who are well eoquainted with you) PRESENT CITIZEN- SHIP NAME ADDRESS YEARS KNCWN . f.) i. 7%, » i sim loco be "pleley ‘- =: 73 24 TRAVE VOU EVER BEEN ARES LED-TINDTETED-OR SUMMONEDINTO COURT ESA D ALPROCEEDING OR CONVICTED, FINED OR [IMPRISONED GR PLACED ON PR ROC : ARRESTED OR REQ- UIRED TO DEPOSIT BAIL OR COLLATERA TRAFFIC VIOLATIONS a ee er re a ee if YOUR ANSWER IS “YES” LIST ALL SUCH CASES IN ITEM 25. IN FACH DATE: (3) THE PLACE WHERE ARRESTED; (4) DISPOSITION OR PENALT 25, ARRESTS (Include aii arrasts and fines other than minor raffic vitlations} CHARGE DATE PLACE WHERE ARRESTED DISPOSITION mswer “Yes or ~No* ae oo Vee a TNE CHARGE OR NATURE OF THE OFFENSEr (2) THE =< s. Pel rae ee J 26. PREVIOUS SECURITY CLEARANCE _* A. TO YOUR KNOWLEDGE HAVE YOU EVER BEEN INVESTIGATED BY ANY BRANCH OF THE FEDERAL GOVERNMENT? .......4; Se a A nse "¥en or RG B TO YOUR KMOWLEDGE HAVE YOU EVER BEEN REFUSED CLEARANCE BY ANY BRANCH OF THE Answer "Yea" or “No FEDERAL GOVERNMENT? « wg oe a we ee we ee ee ee ee ee eee IF YOUR ANSWER TO EJTHER QUESTION A. OR B. IS YES, FLEASE FURNISH DETAILS. Aner Ya" or "Ne CERTIFICATION ~ 7 oe tik zeme a ax TT th =m az x o. citer] po . wou. 1 OQ BE FILLED OUT BY AGENCY OR FIRM EMPLOYING ‘ JRIEF DESCRIPTION OF DUTIES (Description shouldl not reuplt clinsified information) Sa Res Re yp getter mg a) + . 4 » WILL PERSON HAVE ACCESS TO RESTRICTED DATA! OO ves (] no Tate 3. Cun, [WILL PERSON KAYE ACCESS TO AN EXCLUSION AREAT {] ves (Chach tha ona beck applicable) ~ * Pf] FINGERPRINT CARD ATTACHED — ve Soe - .- 4 ve attacuenynn we on . ie iit a came ae ee a A a et i TS — 7