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Pn ve OEE TT PON, RRR ETN Se Se rs cmeteiasnennemnenetememnesienasbeemenenieneemereded in eee HAVE YOu EVER BEEN ARRESTED, C+ y OR HELO BY FEDERAL, STATE, OR OTHE. . ( Say AUTHORITIES, FOR 73. ° ANY VIOLATION OF ANY FEDERAL LAW, $ LAW, COUNTY OR VUNICIPAL LAW, REGULAT, OR ORDINANCE’? INCLUDE ALL COURT MARTIALS, WHILE IN MILITARY SE « DO NOT INCLUDE ANYTHING THAT HAPPE BEFORE YOUR 16TH BIRTHDAY. DO NOT INCLUDE TRAFFIC VIOLATIONS F HICH THE ONLY PENALTY IMPOSEO WAS A FINWOF $25.00 OR LESS. ALL OTHER CHARGES MUST BE INCLUDED EVEN IF THEY WERE OISMISSEO. {- om ma Pauw crs . - me, fJves K) No tf “ves, Give DATE ANO PLACE, CHARGE, AND DISPOSITION: * i . omy » i. * . ro 4 f oes * wes oe * - 4 a ~w ‘ sidy Is . ¢ 21,HAVE YOU EVER SEEN PREVIOUSLY GRANTED AN ACCESS AUTHORIZATION (Security clearance)? (If answer is **¥es**, indicate level of clearance, when grented, by whom and where mB Eres at that time under Item 26, Remarks*’,) . . See Item Remarks Mires Ch)no 22,HAVE YOU EVER HAD AN ACCESS AUTHORIZATION (Socurlly clearance) SUSPENDED, DENIED, OR REVOKED? (If answer }s "Ves", j indicate lovel of clearances, when susponded, denied or rovokod, by whom and where employed under Item 26, 'Remarks*’.) (If you since have “# boon Srantod a clearance by the govormmont, indicate under Item 26, "Remarks" the date, lovel of clearance and activity which restored the cloarance. oe > * 5 . x« 2 . . .. . Cj ves Gd no 23. HAVE YOU EVER TERMINATED EMPLOYMENT WHILE A REQUEST OR APPLICATION FOR AN ACCESS AUTHORIZATION (Security * clearence) WAS PENDING? (Il anewer js *t¥es", furnish name end eddress of employer undot “Remarks**, Jf termination resulted froma reduction in force, so indicate and furnish details under “'Remarks’?, [If you since have been ranted a clearance by the Government . GA xo : i - 24. REFERENCES (Givo tivo Peraonal references, atating busines address of all releroncas, if known. Do not include relatives, former employers, |" indicate under Jlem 26, “Remarks” the date, level of clearance and where employed.) oO Yes or persons living outside the United Statoe.) * 4 25. LIST EACH FOREIGN GOVERNMENT, FIRM, COR TATIVE, OFFICIAL OR EMPLOYEE IN THE PAST 5 YEARS. FOR WHOM YOU HAVE EVER ACTED IN SUCH CAPACITY. * None. 26. REMARKS (Use the space provided below and attach additional sheets, if necessary, for a full statement) Item 21. Secret = 9 April 1958 - INM - Philadelphia ~ R.C.A. | + Penne nao pienr werent . . ‘CERTIFICATION . WARNING: Read every sentence of Certification before signing. +I certify thet T know that any misrepresentation or false state- , . . . t made by me hezein may subject me to prosecution und | . I certify that the entries made by me above are true, complete, men ? ay sub) P er and correct to the best of my knowledge and belief, and are made | Title 18, United States Criminal Code, Sections 911 and 1001, in good faith, pith penalties up to five (5) years imprisonment and $10,000 ine, . I certify that I am a citizen of the United States, I certify that I have read and understand each sentence of this Certification, SIGNATURE OF EMPLOYEE OATE OF SIGNATURE ¢ ADORE! ; RCA. - Camden, New Jersey Ww 4 . ® GPO: 1966 O-227-651 ‘\ "4 we