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UNITED STATES ATomic Energy commIssiOn Form approved Budget Bureau No 38-R001 6 WASHINGTON.D.C (Expireo Seyt 80,1955 .SORNEL SECURITY QUESTIONNAIRE IN$TRUcrIoNs --All sections must be completed Write "None" when applicable Type or pnnt all answers.If space is not ber,street,city,and State 1 NAt4E (La, firs, middle) 5 DESCRIPTION (Checkhch MALE FEMALE tad, D.w1t.N3 ..WA'102102" RACE .HEIGHT WEIGHT COLOR EYES COLOR HAIR 2PTHENAMES Ind 180 Gray Brown Bone whsch 7 BIRTH DATE single dnorceo MONTH DAY' YEAR PRESENT ADDRESS DATE Unvarsity HarrieD wioow(er) 10 30 03 Nashirgton, D. C. 3/15/56 8BIRTHPLACE (Cy couny,Sa Fargo Cass County 4.ALL OTHERADDRESSES FOR PAST 15 YEARS DATE N. Dakots ,Genara? i j uT] rce? IF US CITIZEN, INDICATE WHETHER 45235 Rebraaka Ave. 7/2/44 to 7/20/5) (At DY BIRTR '(c) by NAtuRALIzAtIon Waghtngton, D, e.jy +p- nt (a) DERIVATIVE Petition no .i Hha yhe? nar Spts. + 9. DATE DATE 1940 to 7/3/h4 CERTIFICATE NO. CERTSFICATE NO 1650'Harvard- St, .s.W. PLACE PLACE IF ALIEN. INDICATE ALIEN REGISTRATION NO DATE OF ENTRY 1 PORT OF ENTRY 10.DRAFT BOARD NUMBER AND ADDRESS WLTH WHICH REGISTERED Hone 11. SOCIAL SECuRITY NO 578-52-4899 12 PERNANENT STATION, RANK,AND ADDRESS IF NOW IN NILITARY SERVICE Sone 12A MILITARY SERVICE (Pas or pram) SERIAL NOS BRANCH FROMYrTO(Yr) luq -U9LF maogp #0oy3Hy) N0l1V3n(3, E1 mensary NAME OF SCHCOL ADDRESS FROMX) (x) 01 DEGREES Fargo High School Fargo, H. Dakota 1918 1921 Geo. Waahington-Uniy.. Washington, D. C. 1921 1924 Geo. Wastington Law Sehool. Washington, D. C. 1924 1928 W..B. RECORDED - 7: RECORDED 14.FOREIGN COUNTRIES VISITED (SI9Exd 17 APR 27 1956 COUNTRY DATE LEFT USA DATE RETURNED US PURPOSE Hane b7C SR#* 1058 Page 1