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![handle is hein.jfk/jfkarch11603 and id is 1 raw text is:
1
To avoid delay-1. Read information carefully; 2. Complete application in full; 3. Typewrite or print in ink
A. PERSONAL INFORMATION
I. NAME (Last) (First) (Middle) 2. DATE OF BIRTH 3. SOCIAL SECUR NUMBER
MR (Month) (Day) (Year)
TARASOFF Boris Dimitri Nov 2 1908
4. ADDRESS (Number and street) (City and State) (Zip Code)
CORREs: ancho Contento. S. A., Apartado Postal 2707, Guadalajara, Jal., Mexico]
CHECKS: Union Trust Company of the District of Columbia, .0. Box 481, Ben
Franklin Stn. , Washington, D. C. 20044 (Acct, -110-545):
S (A) ARE YOU 6. (B) IF YES. GIVE THE FOLLOWING INFORMATION: OS -
MARRIED!
WIFE'S OR HUSBAND'S NAME HER (OR HIS) BIRTH DATE DATE OF MARRIAGE ADDRESS OF SPOUSE IF DIFFERENT FROM ITEM 4
(First) (Middle) (Month) (Day) (Year) (Month) (Day) (Year)
YES
OINO Anna May 5 23 Mar 10 45 N/A
B. CIVILIAN SERVICE
1. OFFICE OF ASSIGNMENT 2 SERVICE DESIGNATION 3. LOCATION OF EMPLOYMENT (City and State)
DDP/WH D Mexico City
4 TITLE OF LAST POSITION .. S. DATE OF.FINAL. SEPARATION (Month) - (Day) (Year) 6. APPROXIMATE NUMBER OF YEARS OF
Staff Agent Nov 30 1970 CIVILIAN SERVICE 15
7. DO YOU HAVE FEDERAL EMPLOYEES GROUP LIFE INSURANCE?- 8. ARE YOU ENROLLED IN A PLAN UNDER THE FEDERAL EMPLOYEES HEALTH BENEFITS
YES l NO PROGRAM? YES L NO
C. MILITARY SERVICE
I. COMPLETE THE SCHEDULE BELOW IF YOU HAVE PERFORMED ACTIVE DUTY THAT TERMINATED UNDER HONORABLE CONDITIONS IN ANY OF THE FOLLOWING SERV-
ICES: (A ARMY. NAVY. MARINE CORPS, AIR FORCE. OR COAST GUARD OF THE UNITED STATES: OR (B) REGULAR CORPS OR RESERVE CORPS OF THE PUBLIC HEALTH
SERVICE AFTER JUNE 30, 1960: OR (C) AS A COMMISSIONED OFFICER OF THE COAST AND GEODETIC SURVEY AFTER JUNE 30. 1961. IF AVAILABLE. ATTACH A COPY OF
YOUR DISCHARGE CERTIFICATE
BRANCH OF SERVICE SERIAL NUMBER DATE OF ENTRANCE DATE OF SEPARATION LAST GRADE ORGANIZATION AT DISCHARGE
ON ACTIVE DUTY FROM T.IVE DUTY OR RANK (Div., Regt.. Co., etc.)
16th Reuforcene'
U. S. Army 20 248 288 3 Feb 1941 20 Oct 45 Tec 4 Depot
2. (A) ARE YOU A MILITARY RE- 2. (B) ARE YOU IN RECEIPT OF OR HAVE YOU EVER APPLIED FOR 2. (C) IF YES, WERE YOU RETIRED FROM A RESERVE COMPO-
SERVIST (EITHER ACTIVE MILITARY RETIRED PAY? (RETIRED PAY DOES NOT IN- NENT UNDER CHAPTER 67, TITLE 10. U.S.C. (FORMERLY
OR INACTIVE)? _ . ..CLUDE V.A. PENSION OR COMPENSATION.) TITLE III, PUBLIC LAW 0-8101?
O] YES NO YES NO O]YES NO
D. DISABILITY INFORMATION
2. BRIEFLY DESCRIBE YOUR DISABILITIES. STATE WHEN INCURRED, AND HOW THEY INTERFERE WITH PERFORMANCE OF THE DUTIES OF YOUR POSITION. (ATTACH
ADDITIONAL COMMENTS ON PLAIN SHEET OF PAPER IF NECESSARY.) R URNTO CIA
Baakground Use Only
DO Not Reproduce
E. OTHER CLAIM INFORMATION
1. (A) HAVE YOU EVER RECEIVED OR MADE APPLICATION FOR COMPENSATION I. (B) IF YES. STATE THE NUMBER OF YOUR COMPENSATION CLAIM AND THE
UNDER THE FEDERAL EMPLOYEES' COMPENSATION ACT? PERIOD FOR WHICH YOU RECEIVED COMPENSATION
E YES M~NO CLAIM NUMBER FROM (Month) (Day) (Year) TO (Month) (Day) (Year)
- O YEN
2. (A) HAVE YOU PREVIOUSLY FILED ANY APPLICATION UNDER THE CIVIL SERVICE 2. (B) IF YES, INDICATE THE TYPE(S) OF APPLICATION
RETIREMENT SYSTEM. INCLUDING APPLICATION FOR RETIREMENT, REFUND, AND GIVE THE CLAIM NUMBER(S) IF KNOWN CLAIM NUMBER(S)
DEPOSIT OR REDEPOSIT. OR VOLUNTARY CONTRIBUTIONS? O RETIREMENT DEP S O RD O
E REIREMNT U DEPOSIT OR REDEPOSIT
O YES NO O REFUND CON TBABRTONS
3. (A) HAVE YOU PREVIOUSLY FILED ANY APPLICATION UNDER THE CIA RETIRE- 3. (B) IF YES. INDICATE THE TYPE(S) OF APPLICATION:
MENT & DISABILITY SYSTEM, INCLUDING APPLICATION FOR RETIREMENT.
REFUND, PURCHASE OF SERVICE CREDIT, OR VOLUNTARY .CONTRINIONS. RETIREMENT PURCHASE OF SERVICE CREDIT
O YES NO O REFUND O VOLUNTARY CONTRIBUTIONS
4. (A) HAVE YOU EVER BEEN EMPLOYED UNDER ANOTHER RETIREMENT SYSTEM 4. (B) IF YES. GIVE THE NAME OF THE OTHER RETIREMENT SYSTEM
FOR FEDERAL OR DISTRICT OF COUMBIA EMPLOYEESi YES O) NO Civil Service System
Only applicants for total disability retirement will
complete Part D.
WHEN DID YOU BECOME TOTALLY DISABLED! (month. ye'ae)
A[ LICATIQN FOR RETIREMEI](ViewImageLocal?handle=hein.jfk/jfkarch11603&div=1&collection=&method=preview&ext=.png&size=3)