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104-10121-10213 JFK Assassination Records Archives 1 (10/19/1972)

handle is hein.jfk/jfkarch11015 and id is 1 raw text is: 104-10121-10213
  ease No.-
  NDo not write.in this space)


Requesting Office:


Rp~Ti.~ ~0~~


Backstopped address, if any:


b t l LI


Date: 19  Oct  72


U.S.   DOCUMENT REQUEST FORM


REQUESTS   FOR  U.S. ALIAS DOCUMENTS   FOR  USE  IN U.S.
     REQUIRE   APPROVA OF OFFICE OF SECURITY

 FR/SG              t :                 ocuments are required: ASAP

teredl Alias


/  Wre   out middle name, if any)


If address is to be selected by TSD, list state and cities with which you are familiar in order of preference:

   First choice:                   fGlaryland  Driver's   License

                                          0oI


econd  choic

Third choice:


Height:  5'11  Weight: 198     Hair: Brown    Eres: Brown     Blood Type: A     Married? Yes

Glasses while driving? No - Birth date:_ 26                    Place: CPhoenix29 Arizona


Occupation:
           (Engineer, Intelligence Officer, Government Official, etc.)


Mexican


(White, Negro, Yellow)


Specify country where documentation will be used:

Documentation requested: ar yi nd.License   and   ocial
                        Itter   pertinent   to


Seuri ard.
Clubs
    't -14


As a guide for issuance of appropriate documents, list hobbies, i.e., photography, bowling, shooting, stamps, etc.,

special interests, social clubs, athletic and cultural associations, or professional societies or institutions with which

you are familiar:


Signature exemplar in alias:
(Write name three times)


Supply proper photo or negative for identity document request if required.


    ~,
S...~ .-----


I


e:


Mexican


non.


*

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