“14-00000 % (14) F. IF, TO YOUR KNOW EDGE. ANY OF THE ABOVE HAS CONDUCTED AN INVESTIGATION OF YOU, INDICATE BELOW THE NAME OF THAT AGENCY AND THE APPROXIMATE DATE OF THE INVESTIGATION: .1 29o2..Invoudi;fion ugact, 040... SEC. 26. PERSON TO BE NOTIFIED IN CASE OF EMERGEN”
“INCAPADLE’ the s.° give nan.e an a added a of farin', tt any, who tan mob o such Jocielana bi toes o eeerosr.); 0005 Press DIVDusL ahQe Thar HE was GeN Ca1i0N*190 as rouN BUCNOENCT Domesse# fit e.. saplaws ** to item 2 The persons nomed is it- 3 obev. »y7 eiso ba notified t”
“14-00000 (14) v. IF. TO YOUR KNOWLEDGE ANY or THE ABOVE HAS CONDUCTED AN INVESTIGATION OF -A You, INDICATE BELOW THE NAME OF THAT AGENCY AND THE APPROXIMATE DATE OF THE INVESTIGATION: not..to..my..knowledge.............................................. : She. 26. PERSO”
“GXT6NSO4” NONE is THE NOTViDUAL NAMBO’anovE wit i ING or YOUR AGENCY APPICiAroNt aleo° give name and aindene of organisos Net tr.n 00 belteves’yrw won No .--AIS ICIVOVAL AUTNORegp 10 WKKK DECISIONS OH,YOUR BEHALF G.THEvEHy YOU ARE INCAPABLEN !R NeP give name andledwess of ”
“NAMED AsovE WITtino or YOu AGENCY AFFILIATION? (18 "No” Give name and addross of organisa- (lop ""** * • * 808.) YES NO Lawyer a Secure Denali Mrs Lone Oflawintemay-malie 15 Twis ICIVOUAL AUTHORIZED TO MAKE DECISIONS ON YOUR BfnALF Ih racy EVENT you ARE INCAPABLE? cze "No ”
“(14) F. IF, TO YOUR KNOWLEDGE, ANY OF THE ABOVE HAS CONDUCTED AN INVESTIGATION OF YOU, INDICATE BELOW THE NAME OF THAT AGENCY AND THE APPROXIMATE DATE OF THE INVESTIGATION: SEc 26. PERSON TO BE NOTIFIED IN CASE OF EMERGENCY: NAME RELATIONSHIP ADDRESS ZVY8 LITA" ■ SEC. 2”
“AGREE THAT ANY INTENTIONAL MISSTATEMENT OR OMISSION AS TOA MATERIAL FACT WILL CONSTITUTE GROUNDS FOR MY IMMEDIATE DISMISSAL. 1 SIGNED AT DATE City . State witness Signature of Applicant PAGE •”
“19.,1Y 1 st 4*444 ’ t ylnl o m -**ye - 0 e **h l 1 2 A24 (14) . C ” Z .5 L .7 & F.IF, To YOUR KNOWLEDGE, ANY or THE ABOVE HAS CONDUCTED AN INVESTIGATION or YOU, INDICATE BELOW THE SAME OF THAT AGENCY AND THE APPROXIMATE DATE OF THE INVESTIGATION: None.%....”
“AND WILLFUL FALSE STATEMENT ON THIS FORM CAN BE PUNISHED S7 FINE OR IMPRISONMENT OROTH (S9o U. S. Code, title 18, section I6O1)- Peter C. Ghh DATE 5 Donald W Noble 15 APRIL 1975 . MR DONALDI NOBLE 5314 DENWCOD AVE.OXON HILL,MD. 20022 TEAS SECHSOE To FE COMPLETED BY AUTH”
“INDICATE THE WAWE OF THE AGENCY AND THE APPROXIMATE DATE CE YeE INVESTIGATION. IA NA it mbamunt e * i* t* n * t* G S • 4 5 :5 NOTE SPECIAL H your answer is YES" t the following Grestions 10. 11 or 12, provide the information requested for ooch UTRUCTIONS, Goostion on a sapo”
“1*3 nry:4 AUTHORIZED TO laK pacicus ON roun a wau * ThA Ehyt YOU ARE IhcApasLe* rae “No” "9 dents are wo.ee* c! pers.ar, tf any who eon 0.«>« sauh jeciativia M 4>xo ot aeergency.) 10 b■ AU RNOT FAAT NE *5 dt** ctstanATAu A 1 TOR exann UagEk! -a ** {A Pha perians nameed u. ”
“-00000 50 PERSONAL RECORD QUESTIONNAIRE SECRET " PRO BO. .... PART II - OPERATIONAL INFORMATION Bi*tC* h* NVCA-18757 INSTRUCTIONS ro CASE OFFICER This fore oust be filled in by the case officer or appropribke authority on the Basis of the Sect available in formation. ”
“14-00000 / (14) F. IF, TO YOUR KNOWLEDGE, ANY OF THE ABOVE HAS CONDUCTED AN INVESTIGATION OF YOU, INMCATE BELOW THE NAME OF THAT AGENCY AND THE APPROXIMATE DATE OF THE INVESTIGATION: - - . - Federal Purose of investigation -1966--------- ---------------------- —..... ....”
“14-00000 F.1F, TO YOUR KNOWLEDGE, ANY or THE ABOVE HAS CONDUCTED AN INVESTIGATION or YOU, INDICATE BELOW THE NAME OF THAT AGENCY AND THE APPROXIMATE DATE OF THE INVESTIGATION: Sec. 26.PERSON TO BE NOTIFIED IN CASE OF EMERGENCY: NAME -.RELATIONSHIPS: ADDRESS (SL and Num”
“-53- 1 65 1 63 3121 N # 22 Ct. 8 61 1 65 > IPH LAST FORSoN RESIDENCE OF MORE TEN ONE YEAR IF NOT SHOWN ABOVE APPLICANTS EMPLOYMENT LAST FIVE YEARS. (IF NONE so STATE) Chusband INCLUDE ALL INFORMATION REQUESTED ABOVE LIS T PRESENT EMPLOYMENT FIRST. FROM 2a Tray try68 ”
“14-00000 * esyra SECTION XXIV ADDIT ISKAL INFORMATION 1. DO YOU ADVOCATE so HAVE YOU E CE: AC. CCATED. se A BE YOU he OR FAVE YOU EVER BEEN A MEMBER OF: Cm PAVE YCVE • E 9 %.PPCRTED OR B E% ASSOCIATED • m any POLITICAL PASTY IVID-4L OR CAGAN - vEs 2a” Ce @MICH * CV MATES 0”
“tor.) YES |X NO i -— Yes ------------------------------------------------------------------------------------------------------ IS THIS INDIYIOUAL AUTHORIZED TO MAKE DECISIONS ON YOUR BEHALF IN THE EVENT YOU ARE INCAPABLE? (I0 "No" give name and address of person. If any, wh”
“OVERTHROW OF OUR CONSTITUTIONAL FORM OF GOVERNMENT, OR WHICH HAS ADOPTED THE POLICY OF ADVOCATING OR APPROVING THE COMMISSION OF ACTS OF FORCE OR VIOLENCE TO DENY OTHER PERSONS THEIR RIGHTS UNDER THE CONSTITUTION OF THE UNITED STATES. OR WHICH SEEKS TO ALTER THE FORM OF GOVERNME”
“14-00000 I J28.00L3 YOUR IINANCIAL POSITION PERMIT D1SCMA-GL OF ALL CLB13 %- b. IF NO: RESIDING ABROAD WAVE YOU teLs PAID CyNEUT XYI : hen I’r *NC n.t 3 ";* ser P *%: Gel 57:6 9 "EN ” dADP 5:7 MIE EN ::! Y1 A J.J. INCSAL "As? JVE3 Co0 IF ANSTE? NAMES Or CRUITORS, AMOUNTS”
“fat oech INSTRUCTIONS question on • separate, signed sheet and attach the sheet to this form in • sealed envelope. 0. HAVE YOU, on Po vous VO#L 00€ was Youm spousE. #ves nee ETaiED ARREST FO, NICTep 09 0 VICED Cm ANY VIOLATION OP L w& .A401HEN THAN A WAS O. fRAPGIC ViS.ATION ”
“IN COUP STATEMENTS THAT you MAY THil SDMISABLE. ARE THERE AHV UNFAVORABLE IRCICE+TS f* FOUR LIFE NOT MENTIONED ABOVE WHICH esf 18 DISCOVERED I* SUBSEQUENT INVESTIGA TION, WHETHER YOU WERE DIRECTLY NeG:=ED OR M0T, WHICH MIGHT REQUIRE EXPLANATIC», if So, CESCRIBE, IF NOT, ANSWE”
“AUTHORIZED TO MAKE DECISIONS on you SERALF IN THE-EVENT YOU ARE INCAPABLE? (80 No” NO YES' $1 *0 name and oddrona of person, le eny. who can make such dnclatz 2 casa of seneraincr) 1 NO DoF: THIS INDIVIDUAL KNOT THAT HE HAS ODEN OR3I0N41EC AS • CUR EMERGENCY ADORESSEE? '(i”
“on roun BEHAL*’ tlf N and o-}51e so of porevn, 19 •F Do % THIS tOVID04 ENO THA T ME esplati why in item 6.) Jan 433 SEN DESIGNATED AS IVU* EMERGENCY ADORE9500’ (R9 an 7° : NO t. The persons named in item 3 above may also be notified in case of emergency. If such notifica”
“each sheet your none, oddren date 604 mith, and vta ninction title. Attach to tnaide James Enetl of this ap tection * FALSE SA!EMENT ON THIS APPLICATION IS UNIZUAELE BY LAW (U. S. CODf TITLE ta SEC:CQh/19. I cortily that the statements made b the th Do* uppilanc- are true, c”
“ABOVE, WHICH MAY BE DISCOVERED YER IN SUBSEQUENT INVESTIGATION. WHETHER YOU WERE DIRECTLY INVOLVED OR NOT, WHICH MIGHT REQUIRE EX PLANATION? IF SO, DESCRIBE INCIDENT(S) AND PROVIDE DATE(S) OF OCCURRENCE ON SEPARATE SHEET IN AC CORDANCE WITH SPECIAL INSTRUCTIONS ABOVE. X NO ”
“vov vas Dorothy A. Flores (Spare) give same bid a-Ktress of peroor, *9 an r. who can make such teclelane to Case of emergency.) 06%, this INDIVIDUAL inov THAT ME seas BEEN DESIGNATED AS VOUN EMERGENCY ADOMGSeGR ill anewe, le No* esp/ain sA, • itemn 6.) NO ivr)J No . T”
“he boltoves you wash for.) YES € NO • Ticis IDIOUAL AutsoNIzED to WIRE DECIION4 on roUR BEHALF’ (It "No" qive neme and addenun al porsori, if VES any, who son trek a such decisions try Caso ct emorgen-y.) NO Dose TH DJDOAL KNCE TASiRR HAG 06Ex BRMONATEO AS YOUR EURAJENIT A”
“statement being updated. Attach all sheets to this form. / CERTIFICATION I CERTIFY that the statements mode by me on this form update my Personal Qualifies- tions Statement completed C42227 (month, year) and are true, complete, and correct to the best of my knowledge and b”
“YOU NOW OR HAVE YOU EVER BEEN AFFILIATED OR ASSOCIATED WITH ANY ORGANIZATION OF THE TYPE DESCRIBED ABOVE AS AN AGENT. OFFICIAL. OR EMPLOYEE? X ARE YOU NOW ASSOCIATING WITH, OR HAVE YOU ASSOCIATED WITH ANY INDIVIDUALS. INCLUDING RELATIVES, WHO YOU KNOW OR HAVE REASON TO BELIEVE,”
“M2ESTLATTOR, WItt THOR YOU Wety DIRECTLY INVOLVED OR NOT. WHICH MISItT REQUIRE EX- • PLANATICN' IF 50, DESCRIBE BNCIOHNrls) AND PROVIDE DATE15) OF OCCURRENCE ON SEPARATE SH2E1 IN AC- CORDANCE Nilre SPECIAL INSTRUCTIONS ABGvE. x No SECTION XXY__________ PERSON TO BE NOTIFIED I”
“work tor.) - ; - YES Yes IS T 15 INDIVIDUAL AUTHORIZED TO MARE DECISIONS ON YOUR BEHALF’ (It "No” give name and achtroue of person, if NO tit case of emergency.) any, who can make such decisions tza VES : NO POE% THIS INDIVIDUAL KNOW THAT HE HAS BEPN DESION A TED AS YO”
“14-00000 9 & SECRET * SECTION IX QUALIFICATIONS FOR OTHER OPERATIONS + *DICATE SPECIAL AgiLitity, falet9, OR QUALIFICAtlOns POSSESSED av WuDJrct anice CouLD conctivapLC PL of VALUE Fom O1 ta OPERatiONs. 1 - ce r 1, • *1 SECTION X COMMITMENTS • if It is PROPOSED to pa”
“name and nidreen ct organiza- ton he believes you work tos.) ' VEs VES THIS INDIVIDUAL AUTHORIZED TO MAKE DECISIONS ON YOUR BEHALF IN THE EVENT YOU ARE INCAPABLE? (ft "No” NO give name estel addroan ol peroori, it nny, who can make such doctalona dr case of emergency.) (E”
“soun qanALe IN rhu f VCNT YOU Anu INCAPABLE, fit “No° give n mo a and s00e 1 el moreen, i* any, who 6.7 nase owe" dodlelune be sees of emergence) NO Dv** t * EN0O inav HE was nest besignatso • • rove *MBRORCy sbuneusse 1## anomer t» NG" ""LI A No. The poroono nomel in wee”
“atasowtS} FOR TERMINATION, AND DATE(S)' NA 3. MEMBER’S OF FAMILY NAME or SPOUSE apoerss (No. . Street, City, Zone, State) TELEPHONE NUMDER WANES OF CHILORF NA ADDRESS se* AGE NA NAME or FATHER (or nele suerdian) ADORESs, TELEPHONE NUMBER• C.H. GoodpASTURT PO 522, TIPTO”
“AFFILIATION’ - (0 "No" give name and address of organize- ton he believes you work tot) YES NO IS THIS INDIVIDUAL AUTHOR ED 1 O MAKE DECISIONS ON YOUR BEHALF’ (If "No” give name and address of person, it any, who can make such decisions in case of emergency.) YES NO DO”
“(14) F. IF, TO YOUR KNOWLEDGE, ANY OF THE ABOVE HAS CONDUCTED AN INVESTIGATION OF YOU, INDICATE BELOW THE NAME OF THAT AGENCY AND THE APPROXIMATE DATE OF THE INVESTIGATION: SEC. 26. PERSON TO BE NOTIFIED IN CASE OF EMERGENCY: NAME RELATIONSHIP____ ADDRESS ........ (City) ”
“16. 21202.2 L—You are requested to furnish all information paled for below in sufficient datoll to engbte_the Ovil Zorven Commission and the appointing othoua sa agebrow to determineyour quqithcationa kirgthe position for which you uro acailying, in ms ecaa/an preredwt blow cido”
“NOT IED tee ratl 2* LV1PGENCY. IF SUCH NOTIFICATION 15 NO. DESIPAGLE BECAUSE OF MLALTH 09 GTVIER REASONS, PLTASE to STATE A :TE % 7 &% : -E P,ER5€ SIDE CF tselS FORM. 5. VOLUNTARY EUT IES Suburban Trust Co, Bethesda Br. INDICATE ay BANKING INSTITUTIONS WITH DrICe YOU HAVE AC”
“set was of person, If any, who ton make mech I- cetetousa ‘‘lre Trk Everey 100 Auk st emergency.) U’ tte " Tex 1 DOEE 1H13 *V:Qu*L • RE M2 nEft Desi FtD A9 YOUR EMERGENC « 00625% ? (ze efipou esplain whr tey atom 6.) X The persons named in tee 3 ctovo may also be not.h.ed”
“13-00000 7, 5. b x Page 5 - 6. Do you agree to have written opinions provided to the Committee by the designated agency ethics officer of the agency to which you are nominated and by the Office of. Government Ethics concerning potential conflicts of interest or any lega”
“14-00000 .2 i-A-melt 67 5 the r. re, ar Tr-eso, comoed o Rond • inyn-t-te-s-yo, ■ G. !‘. Freed-ip woorunt 23 street (6c) 29 », fleir Yor: Br 10040 ■ - Cellderden VATInde ■ 500 Moreland. Circle 29 r-colt6z 36-01. 21 Hast Yow.tyr MIN intto JAKIN to custoov, MD ION inVEncan”
“AGENCY AND THE APPROXIMATE DATE OF THE INVESTIGATION. 1 NOTE SPECIALIf your answer is * ES” to the following Questions 10, 11 or 12, provide the information requested for each INSTRUCTIONS I question on o separate, signed sheet and attach the sheet to this form in a sealed e”
“answered ALL questions correctly. ICERTIFY that the statements made by me in this application are true, complete, and correct to the best of my knowledge and belief, and are made in gorxd faith. ‘ *- False statement on this application so punishable by Law (U. S. Code, Des, S”
“the best of my knowledge arid belief, and are made in good faith. / False statement on this application is punishable by Law (U. S. Code, wo SIGNATURE OF APPLICANT ■ (Sign your name in INK (one given, matial de raitials, acd surname). If female, Title 18, Section 80). / pre”
“is THIS INDIVIDUAL AUTHORIZED TO MAKE DECISIONSON YOUR BEHALF (ze "No” give name and address of perea it' YES any, who can make such dectslona ors case of emergency.) X I No DOFS THIS INDIVIDUAL KNOW THAT HE HAS BEEN DESIGNATED AS YOUR EMERGENCY ADDRESSEE? (It answer >»° YES”
“ON YOUR BIBALF 1% THE EJFH T YOU ARE INCAPABLE? (I* "No* gave name and address of person, if any, who can make such decisions in case of emergency.) ves Dorothy A. - Flore s_The.A mericnn E@bis sy Lime, 2oru . _X por rits INOIVICUAL ENO* THAT Nt HAS BLEN DESIGNATED AS YOUR Ew”
“YOUR BEHALF IN THE EVENT YOU ARE INCAPABLE? (It "No" : Vee: give name and address of person, it any, who can make such decisions in case of emergency.) , YES IN° * DOES THIS INDIVIDUAL KNOW THAT HE HAS BEEN DESIGNATED AS YOUR EMERGENCY ADDRESSEE* (It answeri.No ezplan any tr”
“ADOPTED THE POLICY OF ADVOCATING OR APPROVING THE COMMISSION OF ACTS OF FORCE OR VIOLENCE TO DENY OTHER PERSONS THEIR RIGHTS UNDER THE CONSTITUT ION OF THE UNITED STATES, OR WHICH SEEKS TO ALTER THE FORM OF GOVERNMENT OF THE UNITED STATES BY UNCONSTITUTIONAL MEANS?- , x TEA TA”
“WHITE YOUR NAME IN • NATURALIZATION 1661989 YOUR NATIVE ALPHAOZT IN THIS SPACE: . Gustant OF STATUS orwen nptcirn Per-Tamint Pesidacf 8 PELATIES: SEVERE PENALTIES ARC PROVIDED 87 LAW. - FOR KNOWINGLY AND WILLFULLY FALSIFYING .OR CONcEALinG A mareneat PACT.. June 25, 19”