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104-10120-10028 JFK Assassination Records Archives 1 (5/16/1976)

handle is hein.jfk/jfkarch39097 and id is 1 raw text is: 14-10120-10028 .


PERSONNEL  SECURITY PLEDGE  AND
NAME CHECK  INFORMATION RELEASE


       In                         19,      , National Agency Name
on the Subject with  the following results:


,~T I
  ~cWV te d


P - POSITIVE


N - NEGATIVE


     As  a duly accredited represen'tative of the Requesting Agency  named above, I
understand  that all personnel  security information released to me  concerning the
Subject by  review of his file, by memoranda,  by copies of reports,  or by any other
means is furnished  in strict confidence  in connection with my  official duties.
Accordingly,  I hereby pledge the following:

     1.  The  information is for official  United States Government use  only and
         will be handled  in accordance with  its classification.

     2.  The information,  the source thereof,  the identity of informants,  and
         the collection  methods will not be  divulged nor disseminated  to anyone,
         except officials  of the Requesting Agency  named above on a  strict need-
         to-know basis.

     3.  The information  will not be divulged  in any hearing or board action
         without the  prior written consent of  the Releasing Agency.


LL-


DATE


(4-12-43)


               O  USNATU  


FOR OFFICIAL  USE ONLY


q


FOR OFFICIAL USE  ONLY


W.


NAME OF SUBJECT (Last, First. Middle)        REQUESTING AGENCY       DATE


DATE OF BIRTH       PLACE OF BIRTH                                   DATE OF REOU T


FBI  ONI  ACSI   STATE   PASSPORT  CSC  HCUA   OSI  OSI/4   I&N  AGO   DODCI J


REMARKS:


FORM j  9  S P.EVIOUS EDITION~
10-69


Al->.- 4 j


AE

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