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ae f . " + . nr a 4 AUG-31-1954 14:35 FROM @ UM IT TO e WMFO Pas 5 Standard Form 86 , _} QUESTIONNAIRE FOR Poot em ead - US.oMce of Personnel Man SENSITIVE POSITIONS - een AgaMOont . FPM Chapter 732 (For National Security) 88-110 Part 1 EE Agency Use Only (Complete it items A through P using instructions in FPM Supplement 296-33) E Nature of E Date of Month Gay Year Action Codef 1 | Acton | | { { A Type of investigaton | Geographic Location J sol N OPAC-ALC Number P Requesting Official O Accounting Data andor 1 to td t dt | agoney case Number ot 7 plaphone Number ers¢ ) Date — Persons completing this form should begin w ns below. Please type or print your answers. 1 FULL +I you have only initials in your name, use them and State (KD), - you ave & “Ur.” “Sr. “IL” etc., enter this in the box aftat {2 DATE OF) i NAME — = ttyou have no middie name, enter “NMN." your middle name, Middle Namesn- = sitet) MA yay, Veat 3 PLACE OF BIRTH Use the two letter code for the Stale. 5 OTHER NAMES USED Give other names you used and the poried of time you used them (lor example: your maiden name, names] by 8 forner mariage. former namelsh aasies), or nekoarmats). ‘s the other name |s your maiden name, out “nee™ in front of it, Name Name AER Hem (feet and inches) Wergnt (pounds) Hair Color Eye color Sex (mark one Box) 6 + NEO RMATION 5140" | 4170 | white | Brown |Female | AMate 7 TELEPHONE Work (include Area a and extension) Home (ineiude Area cove) NUMBERS ( Day (202) 273-0375 lam a U.S. citizen by birth in the U.S. een ems 5 and 3 Manscionoont to eto you {LamaUS. czon, bi [was NOT bom Fe US|. [Arora be, aod mae Tana US ae G UNITED STATES CITIZENSHIP If you aré 2 U.S. Citizen, but were not born in the U.S., provide information abou! one or more of the following proofs of your citizenship, aturalization Certificate ( re ware you naturalized?) Court Giiy vou Mothers Mawon Nano aq ida Fishuan § CITIZENSHIP | a Mark the box at the right that applies to you and follow the ay/Year inaued ~ Sta Gertificate Number Gitizenship Certificate (Where was the certificate issued?) ty tae = Cerificate Num . Mo thiDay, ery 13, 7 MQ -{ sili 203 fate Department Form 240 - Repert of Birth Abroad of a Caizen of tha United States aa nag Give the dale ihe form was = MontyDay/Year ; Explanation . we, A prepared and give an LAA: bWKA’ explanation if needed. \ | a, ( . US. Passport 7 atte Ws Passport Number ontvoay/vear (iued This ray be either a current or previous U.S, Pasepod, d DUAL CITIZENSHIP If you are (or were) a dual citizen of the United States and another Country 7 (TAC country, provide the name of that country in the space to the right, “= ai @ ALIEN If you are an alien, previde the following Information: y Place You Entered the United States: AUG 31 °?34 13:14, ) mL aN eGe S24 1373 PAGE. 885