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104-10121-10219 JFK Assassination Records Archives 1 (12/10/1971)

handle is hein.jfk/jfkarch39314 and id is 1 raw text is: 


base No__ inti   _sae
(.Do nlbt writ~ in this space)


SECRIEF


Requesting Office:


9A ---   it ~ -


Date  ~L%-~J:.c ~


       U.S.   DOCUMENT REQUES                  FORM

     REQUESTS  FOR  U.S. ALIAS DOCUMENTS -OR USE IN U.S.
          REQUIRE  APPROVAL   OF  OFFICE OF. SECURITY

               i~ '    stte                 ocuments arEqu-

Registered Alia :d                                name if ary)
                                    (rite out middle name, if any)


Backstopped address, if any


/


If address is to be selected by TSD, list  te and cities with wh  you are familiar in ,rder of preference:

   First choi-e:

   Second choice:

   Third choice:

Height:   -6    Weight: Z       Hair:          Eyes:           Blood Type:Married?

Glasses while driving?      Birth date: %(4                     lace:         A-/

Occupation:                              C4 ?AA iLP /j  Race:_________________
           (Engineer, Intelligence Officer, Government Official, etc.)    (White, Negro, Yellow)

Specify country where documentation will be used:

Documentation requested:    Lw       p-       C.              c 1-1 0C 6, c ,--





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)


7   ~j~)


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


        -----------*q-


Ajj

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