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21 IF YOUR ANSWER TO QUESTIONS17 OR 20 IS*YES"STATE THE NAME OF THE ORGAN ON,DATES OF MEMBEKSHIP, ANU EX- TENT OF PARTICIPATION AN EXPL REGARDING MEMBERSHIP IN ANY OF THESE OR Zations may be furnished under ITEM NO 27,IF YOU DESIRE TO EXP THE CIRCUMSTANCES OF YOUR MEMBERSHIP NAME ADDRESS EROM O- OFFICE HELD pe RELATION NAME IN FULL AGE ADDRESS COUnTRy OF BIRTH PRESENT CITIZEN. Fathar Edwin Freemont Ladd Decessed U.S.A. Motber Risoah Sprogl. 90 8009 Barron St., Takoma Park, Md.,U.$.A. U.S.A wife 52 Ceneva, Fla. U.S.A. U.S.A Father-in-l, David G. Ff iifer Deceased U.S.A. Mothar-in-lw, Nell Gross Pfeiffer Deceased U.S.A. Brother 54 Claveland, Ohio U.S.A. U.S.A Brother Paanl Aunt U.S.A. Sitr -USAT y*g'f-- 23 REFERENCES reatses or emgoyers sh re w NAME AODRESS EARS XNGAN b7C R.SUMMONEDINTO COURT AS A DEFENDANT IN ACRIMINALPRCCEEDING.OR CONVICTED ERAL FOR THE'VIOLATION OF"ANY LAW, POLICE REGULATION OR ORDINANCE TEXCLUDING MINOR TRAFFIC VIOLATIONS)7 25 ARRESTS (Include all arres and fines other shan minor tmffic iolations). CHARGE DATE PLACE WHERE ARRESTED DISPUSITION None Zo previous security Clearance. GOVERNMENT? B To your knowledge have you ever been refused clearance by any branch of the FEDERAL GOVERNMENTT IF YOUR ANSWER TO EITHER QUESTION A OR B IS YES,PLEASE FURNISH DETAILS CeRtificaTiOn HAVE READ_ALL OF THE ABOVE QUESTIONS AND REVIEWED THE LIST SECURITY CL EARAN NILL USED CEMEN RDISMISS TITLE IBUSCOD AAT nionly TO BE FILLED OUT BY AGENCY OR FIRM EMPLOYING BR1EF DESCRIPTION OF DUTIES (Dacrapton should not revea! clazsfied tnformation) NAME OF AGENCY OR FIRM ADDRESS will person have access to restricted data? yes .no WIll PErson Have Access to an ExclusiOn areA? yes no Check the one biock appicadle FINGERPRINT CARD ATTACHED 1-4 ATtached FILE CHECK) (SignATURE AND TItLE OF OFFiCIAL REQueSTing CLEARAnCE)E Page 3