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REFERENCH Iyung # the Unsted States or. Terrurorres of the Unued States who are NOT RELATED TO YOU AND WHO sted under Icem 16,EXPERIENC Do not repeat names of supervisors FULL NAME PRESENT BUSINESS OR HOME ADDRESS Give complete current address BUSINESS OR OCCUPATION Atty b7C 2. Sen. William Langer Wash. D.C. U.S.Senator. Sen.Stylea Bridges Hash. D.C. U.S.Senator INDICATE ANSWER BY PLACING X"IV PROPER COLUMN YESNO INDICATE ANSWER BY PLACING ~X IN PROPER COLUMN YESNO 23 () Are you cttizen of the Unated States of. Americe.. 28 May snqusry be made of your present employer regarding nited States of Arnerica? X ouerecer Organization nayal seryice 34 Are you now, or have you ever been, a member of a Fascist If your answsrns Yesgwe delasls in Item 34. 30. Are you an offcral or employee of any State, Terntory, county,or municipality If your answer ns"Yes, gise detasls in ltem 34. X ehszatio Communsi,or appointmeots examnstons or accepting civt service If your answer y, "Yes" gwe dates of and reasons jor sucb the Unued 4 as'"sA s 3aogp'Sz ao 'ft"Et uosanb oj 3msug Jok jI 32 A Have you ever been discharged from enployment because x sbeet to br attacbed to (2) Your wotk was not saustactory? rosementskroups. bersbip. actrvties tberein and aks any 1 (2) Your work was not satisfactory? I 26 Docs tbe United States Govemment employ n a civlian C .Have you ever been discharged from the Armed Services under other thaa honorable condations Ij your answer to A,B, orC ss Yesgwe details sn Item 34 27.A..Have you any physcal handicap, chronic dusease, or other 33 Haxe you cyer been.arrested charged. or. beld by Federal. or ordinsace?. .law...gulztion B Have you ever had a nervous breakdown? X irthday Do not snclude t c yolarsons for whsch C Hie you ever had tuberculosss? included even f they were dismissed less wa All otber charges must be If your answer to A, B, or C n "Yes," ge detarls in Jtem 34. If your answer Isem34 for each case (2) Indicate stem numbers to which answers apply Iten No Jtem No 29.. I receire.retirsment pay from. the.U.S.CixilSerrlee.fer my. but not If more space n required, use paper the same sire as this page Wrate on each sheet your name, date of birth, and examinauon title Attach tggth3ide of tbs applcaton ectly and Iecided on the basis of all the facts etermut 1.your record 1 I CERTIFY that t by me in this applrcaton are true, complere, and correct to the by n good fauth fof my knowledge and belief, and are Dat Signature of spplicant YERNMENTPRINTINOFFIC