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104-10172-10325 JFK Assassination Records Archives 1 (9/1/1957)

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13. BIRTH DATE
     C.192
[4. BITH PLACE

5 . CI TIZENSNIP

6. PRESENT ACTIVITY AND LOCATION
  reputed  to  be the girond  emsui   or &.aiotant
  of  Sergqmev,  4



7. OCCUPATIONAL 'SECIALTIES, EDUCATION


8. MILITARY SERVICE


    RESt.!2SE   TO  GREEN   LIST
       REQUEST   NO.



REQUEST  FROM
           *AM(4 CF CRIGIWATIXG OrFICER
        Kst/ uracby

  ?~~BuILOIIG
FTESSION     ICV6 J


14. 1145 COXT',rhA.  SEARCH REQUESTEC?


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   -y-IRisT Till( SU64WITTED
   -ADDITIONAL DATA
     COVENI SAME
16. INTEREST IN SUBJECT
     ESPO-JAGE OR Cc ACTIVITT
  O....PEATIONAL CLEARANCE

17. INFORMIATION REQUIRED

  AU


     9. PAST SRYEi-                        SPCA                                         At_____
     9PATOCCUPATIONS                                                              _________
                          ACTIVITY                                LOCATION             DATES-
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13. OTHER SIGNIFICANT DATA (POLITICS. RELIGION. ETC)               ATTACH EXTRA SHEETS WHEN NECEDED
belon-,s  to  CIP


INSTRUCTIONS: INSERT CARBON: FILL OUT FORMS COMPLETELY.
                              SEND   BOTH  SHEETS   TO   FIISTD.                  SEE  CSI-10-7
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