◆ SpookStack

ER] pare sept eet ON ete ‘_CENTE a) : sie ‘ po 4h ota aa" Re OM er Neer PEA TATE TRE SMES ADO CF peer TTF no AEN ERE: Ne a “ . _ ROEPARTNENT. OF. =NgE DATE . eimeiO6] coro: Approved “ a [7 .? Pet AEC SECUR UTY quips Ed roe sette nbe AGG air Budgot Buroau No. 22ross 3 ‘ Ht yaa ONS: Five (5) copies of accomplished form will = Submitted for U.S. Citizens by ihe Contzacye: when ia I prestige ation ie clearance by a military department is récsired, hy, RE OR PRINT ALL ANSWERS. If moré space is required, attach additional sheets, identifying by corredifoh dings Blot fumber, FORM WILL NOT BE ACCEPTED UN- [ LESS COMPLETE LY AND PROPERLY EXECUTED. Cugstion thich do not apply will be marked JtNone"’, NOTE. ~ PENALTY FOR MISREPRESENTATION - Failure topln@westail juestions, or i yt fs cealment, or by misleeding, false, or partial answers) may servé as a basis for denial o te ment of Defense information. In addilion, Title 18 Uniled States Code 1001 makes it eS SEY gby @ maximum + of § years’ impriscnment, $10,000 fine, or both, tmowingly and willfully to make a eet ome, wo Hore ae to any Depart: ment or Agency of the United States as to any matter within the jurisdiction of any Depétt gnt fo) sAgghey fof ie Slates, This includes any statement knowingly and willfully made by employer or employee eb te whichcisdkh figly, @prrect, incongle? or misleading in any important particu ‘a Title 18 United States Code 911 states “‘whoever false “yds iter, epresents hin- self to be a@ citizen eR RSs UNE e At M31 be fined not more than $13000 or imprisoned not more, than’? Peeee sees, or both’, yest cory OF . ° * TO BE COMPLETED BY EMPLOYER’ . i AAT 8 eee em FN ee eri mene, Ca enn Rates ane! men 4 ipRentation (by omission or con- LUG fate i to classified Depart aa ne NAME AND AODRESS OF EMPLOY ER (if 4 subsidiary, include nume of . patent company) é Defense Industrial Security Clearance Office Radio Corporation of America ~ DEP H oorense Supp Agency s Attn: . Security Officer ° i io . Camden, New Jerse. 0830 1 JOS TITLE AND DESCRIPTION OF EMPLOYEE'S DUTIES WHICH REQUIRE ACCESS TO CLASSI FIED. CONTRACT NUMBER, WHEN AP ° IN FORW ATION . PLICABLE . i Government Request : Cleaner ~ Duties require access to classified. eee . > Sy + oe . TIO F information. J CL. k a -~ MATERIALS OR INFORMATION t » EMPLOYEE WILL HAVE ACCESS TO b CLEARANCE REQUESTED is? CC] interim [7] UNDER PAR. 26, ism foe . - ,peCcrst . .. . | CERTIFY THAT THE ENTRIES MADE SY ME ABOVE ARE TRU XCCMPLETE, AND CORRECT TO THE BEST OF MY KNOWLEDGE ANI : i hE BELIEF AND_ARE MADE IN GOOD FAITH. : '¥ rs TO BE COMPLE 4 FF AST NAME, FIRST NAME," MIDDLE NAME R ant . vy name; designate whic: LY « : i LIVEZLY, Charles Augustus None . b6 * ES OATE OF BIRTH 4. PLACE OF BIRTH ” ; _ BS. SOCIAL SECUMITY NIOTC 19 Nov 1807 Philadelphia, Pennsylvania ; ~ 10-2 2-2) ho6 ’ qo. MARITAL STATUS 7. SEX id 8. HEIGHT 9. WEIGHT 10. COLOR EYES , COLOR HA! AR a “Single _ “Male 69" 200 Blue Red 12. EDUCATION (Account for all civilian schools) LF, Z Qa “a —_— NAME AND LOCATION aed a jasspore Grammar School i ise8 dune tooo nes 12 Me S aijeat of your inquiry, CITIZENSHIP C lNo Mf answer is ttyea’t, complete foliowi mn iPan ee is **NQ’*, fetura . | a EIN "> ARE YOU A CUTIZEN OF THE UNITED STATES? ik] yes thia {erm to your employer >) Was) a {AM A CITIZEN OF THE UNITED STAYES BY REASON OF: x] BY BIRTH IN TRE ee STATES: 1 A WSeg se TURALIZE® a Vs om i CITIZEN SHIP*; 1 J SY ORTH IN A FOREIGN COUNTRY OF UN! TEDISMATES sieakhe; pith: BY CERIVA tive’ citizessmin® rrr en fh Sade — rete ernest ne *it chocked cosplete oithor “cltizens Aipsbs; Naturalis zation’ of “ontize pashlp by Derivation®® Section cena nr met aN bare eriTRn bite we 9 Jain RTE rtniR TRA Wares Loo er ¥ _ CITIZENSHIP BY NATURALIZATION™ pprnenc NATURALIZED (City, Cow ty, State) " selow, oa DATE NA PURALIZED N/A CERTIFICATE NO, i, N/4s us sia rc 4 if 3 aa ___ CITIZENSHIP 8 BY sy DERI RUBLES bes ’ PARENT'S CERTIFICATE NO. Y ert enactxmunaceannten ieamceonccene XE LIEW CHAPALA a LAST FED TR NIC OIE PETTITT Neneh Wah ASE VENI EAS REPLACES EQITION OF 1 MAR 64 WHIGH MAY BE USED UNTIL EXHAUSTED jt a a obs > oa] ae wo a z wee