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104-10129-10002 JFK Assassination Records Archives 1 (8/31/1961)

handle is hein.jfk/jfkarch83492 and id is 1 raw text is: 1 2023 RELEASE UNDER THE PRESIDENT JOHN F. KENNEDY ASSASSINATION RECORDS ACT OF 1992 DO NOT USE IS SPACE ISSLUED BY ' PERSONAL HISTORY STATEMENT THIS DATE (FHI In) qu&usT 3!, /96/ INSTRUCTIONS - 1. Answer all questions completely or check appropriate box. If question is not applicable, write aNA. Write Un- known only if you do not know the answer and it cannot be obtained from personal records. Use blank space at end of form for extra details on any question for which you have insufficient space. 2. Type, print or write carefully; illegible or incomplete forms will not receive consideration. 3. Consider your answers carefully. Your signature at the end of this form will certify to their correctness. Careful completion of all applicable questions will permit review of your qualifications to the best advantage. SECTION I GENERAL PERSONAL AND PHYSICAL DATA 1. FULL NAME (Last-Pirst-Middle) 2. AGE 3 SEX pfR/iE Z E I Lt! tM*c 33 ERQS NT'r MALE FEMALE 4. HEIGHT 5. WEIGHT 6. COLOR OF EYES 7. COLOR OF HAIR 8. TYPE COMPLEXION 9. TYPE BUILD $ /oa. /$O/is. '73RoLAN <'Cu4D 10. SCARS (Type and Location) NOAN E 11. OTHER DISTINGUSHING PHYSICAL FEATURES ,ogAE 12. CURRENT ADDRESS (No., Street. City, Zone, State and Country) 13. PERMANENT ADDRESS (No., Street, City. Zone. State and 936/ J .w.' t 8 ST Country) AND PHONE NO. - q3 / s. w, /7 'S. Cdas8 . ' E ! E S7, FLA. E 14. CURRENT PHONE NO. 15. OFFICE PHONE NO. & EXT. 16. LEGAL RESIDENCE (State, Territory or Country) CEdt S- 83 I/ j N~4- Fto R ! ' , 4. S Q . 17. NICKNAMES 18. OTHER NAMES YOU HAVE USED No AE E A//o (T'MZi9LZ(, 19. INDICATE CIRCUMSTANCES (Including Length of Time) UNDER WHICH YOU HAVE EVER USED THESE NAMES. f4' 1QPRl /fD Ta pRES6v7 / G& '/AVaNACg . /ND MI4! F~q- 9s uNDACavE& 44ME 20. IF LEGAL CHANGE. GIVE PARTICULARS (Where and by What Authority). SECTION it POSITION DATA 1. INDICATE THE TYPE OF WORK OR POSITION FOR WHICH YOU ARE APPLYING 2. INDICATE THE LOWEST ANNUAL ENTRANCE SALARY YOU WILL 3. DATE AVAILABLE FOR EMPLOYMENT ACCEPT (You will not be coneldered for any position with a lower entrance salary). $ 60d.0 ,0 COMT4'T#er ERA y S/6 9Yy ' 4. INDICATE YOUR WILLINGNESS TO TRAVEL OCCASIONALLY FREQUENTLY CONSTANTLY OTHER: S. INDICATE YOUR WILLINGNESS TO ACCEPT ASSIGNMENT IN THE FOLLOWING LOCATIONS (Check (X) each item applicable) WASHINGTON, D. C. ANYWHERE IN U.S. X CERTAIN LOCATIONS ONLY (Specify); OUTSIDE CONTINENTAL U.S. 6. INDICATE WHAT RESERVATIONS YOU WOULD PLACE ON ASSIGNMENTS OUTSIDE THE WASHINGTON. D.C. AREA. A'EC4UsvTE 'PA'/ 4'N L/Y/N COND/T/v .S AR SCL.F AND F9M/4y FORM444 USE PREVIOUS EDITION. 11-5844 14) -1- r 1104-10129-100021 j I 0 zi

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