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SE tony ae Mable hs eve ha BIE ER aE dtr = yoo - t 16. If no witness is otherwise available, the Government Officer, receiving this application in person shall serve as such witness upon request. Mailed applications MUST be signed by a witness as well as by the applicant. Signature of Person Filing Application Signature Witnessed By: J EG i or = = of Such Person Address of Above Arlington, Va. 22204 Typed or Printed Name of Witness March organizer, Position or Responsibility of Such Address of Witness Person Relative to Proposed . Demonstration Telephone Numbers of Witness Da Evening Same . Telephone Numbers of Person Filing . NOTE: Under 18 U.S.C. 1001, any person who knowingly and willfully faisifies, conceals, or covers up by any trick, scheme, or device a material fact, or makes any false statements or representations, in respect of any matter within the jurisdiction of any department or agency of the United States, is liable to a fine in an amount up to $10,000, and imprisonment for not more than five years, or both. SHY dWNOU TR i “Ale Glad 90 ' |] OMe Q3Ai393u b6 b7C b6 b7C b6 ~ bIC b6 | BIC