“-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. ”
“.+8 PR J NO. PERSONAL RECORD QUESTIONNAIRE PART 1 - BIOGRAPHICAL INFORMATION INSTRUCTIONS: 1. Write clearly. DISPATCH K0. 2. Answer all questions. If question is not applicable, write NA." 3. Attach blank pages, i f additions! «psee is needed. SECTION I GENERAL PERSONAL AN”
“14-00000 • • ** PRO NO. PERSONAL RECORD QUESTIONNAIRE PART 1 - BIOGRAPHICAL INFORMATION INSTRUCTIONS: 2. Write clearly. DISPATCH NO. 2. Answer all questions, if question de not applicable, write "NA. 3. Attach blank pegen, if additional space le needed. SECTION 1 GENERA”
“14,00000 1 4 PERSONAL RECORD QUESTIONNAIRE I--------- PART I - BIOGRAPHICAL INFORMATION i INSTRUCTIONS 1. Write cteorls. p.sPAtH NO. 2. niwer vl? uueifs0n% If Question 1 9 not applicable, weste *5.4 et __ ___ .____ Attach blank nagen.ef nuastionpt anice-as needed SECTION”
“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”
“14-00000 I i me 2,‘‘% ORE: PRO NO. PERSONAL RECORD QUESTIONNAIRE . PART 1 - BIOGRAPHICAL INFORMATION INSTRUCTIONS: 1. Write clearly. DISPATCH NO. 2. Answer oil coestient. If zettien ft net apelicabl- wrs’e NAn atacn Jians pages, it additional space su needed 1 SECT”
“r « * / SECREI TTAl nA i 3 i PERSONAL RECORD QUESTIONNAIRE 09WPBran R. O. PART I - BIOGRAPHICAL INFORMATION INSTRUCTIONS: 1. Write cleerly. DISPATCH so. 2. Answer all questions. If question it not applicable, write “NA" J. Attach blank petes, if additional enece ie se”
“1950 NOTE SPECIAL II your answer i» *YES° to the following Questions 10, 11 or 12, provide the information requested for each INSTRUCTIONS question on • separate, signed sheet and attach the sheet to this form in a sealed envelope. 10. HAVE you. 04 ro YOUR KNOWLEDGE HAS YOUR”
“record up to date. - war 3. Your cooperation is requested in completing the questionnaire as y r- thoroughly and accurately as possible and returning it to your Administrative Officer within the time allotted.. George E. Melon SECRET Security Information FORM NO. 47 .”
“TO Voun KNOWLEDGE, ANY OF fir Anovr. HAVE CONDUCTED AN INVESTIGATION OF YOU, INDICATE THE NAME OF THE ACENCY AND THE APPROXIMATE DATE OP THE INVESTIGATION. • CSS 1943 U.S. Arrer 1956-57 A 350 1946 ACSI D of A 1959 010 1947 CIA 1948 49 NOTE SPECIAL If your answer la "YES"”
“14-00000 PHO so. PERSONAL-RECORD-QUESTIONNAIRE- PART 1 - BIOGRAPHICAL INFORMATION INSTACt:oes s. W*‘*e rtearlv Weste ai se Afre NO. 2. Anveer all questions. If question , Pvot applicable, ersto "NA° 3. Attach blant rages, of t-hf1 1 IKH *1 (nec 19 nooioil • SECTION 1 GEN”
“INVESTIGATION OF YOU, INDICATE THE NAME OF THE AGENCY AND THE APPROXIMATE DATE OF THE INVESTIGATION. UNK NOTE SPECIAL If your answer is "YES" to the following Questions 10, 11 or 12, provide the information requested for each INSTRUCTIONS question on a separate, signed shee”
“persons to overthrow or overturn the government of the United States or any state or any political subdivision thereof by force, violence, or any unlawful means?...... .................................. ............................ ...............................................”
“14-00000 1 Military service services ora Give 1 details if ever prisnor of war f 9 A o G Present ganization (pr a pol ei tec( VAAcQ I Spe abilities, hobbies / Financial status - earnings, bank sits, secur proper dates dresses, reasons for leaving. Include”
“14-00000 aNsu 11 QUESTIONS BY PI AC 1N86 "X IN PROPER Coxt. Vh 2% Are urses a citizen of ihr United States oof Amenca’... If ' More," give • ountry of • Im h pin are a citireti; . 26. Are yesen now, ne have you ever been, • member of the Crefrimncanisst Party, U.S A., the ”
“14-00000 a 0 27. Habilidades especiales, oapacidades, aficiones, (radio, fotogra- fia, oto.) mone 28. Situation monetaria - sueldo, depdsitos en los banoos, bonos, pro- piedades. 29. Datos de empleos - olase de trabajo, sueldo, fechas, patrones, di- recoiones, razones”
“|4-00000 I • • p* * SECTION XI _ __ FINANCIAL STATUS 1. AnE vey ENTISEL Y DE reenter t yOOn SALARY , _iere 2. IF youn ANSWER is "4O" 10 fur ARDVr. St AT L SOURCES OF 01 HER INCOME ). CANKING INSTITUTIONS WiTl WHICH YOU HAVE ACCOUNTS NAVE or * /1r-/rtr ADONE90 (Cite, S”
“questionnaire as thoroughly and accurately as possible and returning it to your Administrative Officer within the time allotted. CODED J1 -OR gil H- Wo George E. Melon SECRET Security Information may so, 1, Ft 1982 182 37-182 h-::i 'I■ welveninyade”
“(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”
“(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) ”
“WHICH RELATIVE #:91015 4 s. CITIZENSHIP (Country) 6. FRCQUrNrV Or CONTACT /. DATE OF LAST CONTACT B. SPECIAL NEMARKS, i/ ANY, CONCERNING THESE NrLATIVES SECTION V FINANCIAL STATUS L. ANE YOU ENTIRELY Dt PENDE NT ON YOUR SALARY? XTas 7. DO YOU HAVE ANY I INANCIAL INTERI ”
“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”
“completing the questionnaire as. thoroughly and accurately as possible and returning it to your Administrative Officer within the time allotted. .// George E. Melon SECRET Security Information FORM BO. 37 14-158 MAT 1932 */-*0”
“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”
“--------------------------------------------------- • —Fr------ P—27ue.------------------------------------------------------------- IFTYES. DESCRIBE THE CIRCUMSTANCES. ATTACH ADDITIONAL SHEETS FOR A FULL DETAILED STATEMENT. IF ASSOCIATED WITH ANY OF THE ABOVE ORGANIZATIONS. SPE”
“14-00000 torwosp.4 •. +R. • * sa, PLLATIVES RI BL000 04 MARRIAGE NOA RC 6IDI+ IN OTIG COUNTRIES ARI0N34iP secerss +5, LIST PRESENT OR romuge FOREIGN CONNECTIONS a. Business | a. furcovurut *4, pots YOUR PRESENT.FINANCIAL POSITION PERMIT DISCHARGE OF ALL CURRENT DEBTS?”
“34-00000 SECRET (aheo Fillet (") SECTION HI CON TIUED FTO1 PAGE1 71. DATES v MILITA9Y SERVICE 0: 0000 Prom. ??- BRANCH or SERVICE 2a COUN’M, •!»» enico MllItaRy Staling StriLtatEo A 2 4 DETAILS Or OTHER covrasvesf seoait!, 0.9. 0'‘ OPLIGN % /' SECTION IV RELATIVES B”
“L RECORD QUESTIONNAIRE PART 11 OPERATIONAL INFORMATION INSTRUCTIONS TO CASE OFFICER DISPATUFCA-19738 Thee form must be filled in by the case officer of appropriate authority on the basis of the best available in formation. It is not to be shown to the subject. 2. Vormally, headqu”
“XSNO ARE YOU NOW OR HAVE YOU EVER BEEN AOOICTEO TO THE USE OF HABIT FORMING DRUGS SUCH AS NARCOTICS OR BARBITURATES? YES XDuo ARE YOU NOW OR HAVE YOU EVER BEEN A CHRONIC USER TO EXCESS OF ALCOHOLIC BEVERAGES? YES ONO IF THE ANSWER TO ANY OF THE ABOVE IS "YES." EXPLAIN IN ITEM ”
“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”
“0006 •060 26 ’ Residence Oc) address 6•00 26 Occupation or business • o< • €00 26 d Business or employment address • 0 0 26 e) Citizenship status •• e 6 0606 0 • o 26 Ie Alien.............< • 0 26 .II. Naturalized citizen III. Native-born citizen ••• (f) Nationality back”
“WERE POSSIBLE. 0 €e:: 7 CS 30 . to 6 EXPLAIN ANY SITUATION On INC:SCRETION IN WHICH SU BJICT MAY HAVE BEEN INVOLVED •-!. MUST 0€ ELA UATED FROM & CE/OPERATIONAL seCuRitv ViePOInT. : 0 -•• i (o°o o■ • yus) -reenne;.. vo4v - --A6 wur eci‘ - 1 SECTION XII SUBJECT’S P”
“Residence address 000 •• 26 Occupation or business • • • € 26 seshpeuka speli-eniiatew^fe^r^^^^^^#^^ c) d) Business or employment address • • 26 e) Citizenship status e«* 0 26 I. Alien • • • 26 II. Naturalized citizen• 26 III. Native-born citizen 26 Nationality backgrou”
“14-00000 0 4- (Name and Chapter) (81 and Numbs.) ingi (State) (Country) DATES OF MEMBERSHIP:- 5.__ (Name and Chapter) (L. and Number) (0G (State) '(Cenury) DATES OF MEMBERSHIP: 6---- (Name and Chapter) - ist. and Number) (City) (State) (Country) DATES OF MEMBERSHIP”
“NAME OF THE AGENCY AND THE APPROXIMATE DATE OF THE INVESTIGATION. An investigation ( I do not know by whom) was conducted prior to ray departure for Bolivia where I was attached to the American Embassy. This investigation took place during August and September of 1958. If”
“14-00000 J A SECRET FaNen Pilled In) St CTION V°C ONTInUED FROM PAGE 2 4. wave YOU EVER BEEN IN. OR PETITIONED FOR. DAN«RUPICY+ J .ese I 4. S. If YOUR ANSWER IS ves" TO THE ABOVE QUESTION, GIVE PARTICULARS, INCLUDING COURT AND DATE(S) 6 00 YOU RECEIVE AN ANNUITY FROM THE”
“s. CITIZENSHIP (Country) 6. FREQUENCY of CONTACT 7. DATE OF LAST CONTACT . FULL NAME (Loot-Pirot-Middlo) J. RELATIONSHIP 3. ACC a. ADDRESS on Counray st WHICH RELATIVE RESIDES 4 5. cniatwiT (Country) 6- FREQUENCY or CONTACT / DATE Of LAST CONTACT 9 SPECIAL RINAS, IF ANY.”
“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”
“1 4-00000 SECTION XXIV ADDITIONAL INFORMATION 1. 0o *3o 0vocerf C4 **. € V EVER CvOcaten. 99 anp OU ca- •Ou €F Dne Ct • V299ED DF, sev Co Over $715714* n Ni’ve Awe / ?v "c?1* CA.AL % Casas. •245I0* •* KPVOCARE alHES wr Ovretunga of rue 7 40€ IQLE%t24 *- 20 CNCON,’ , %AL ur”
“for aver tin >1 meniter >4 any organiastia thuat|j orgoniastira that , Service dumint time ot W ir' , wives oine the overthrow of the Covarninent c the Un.’ad Statma! try te oue violence?..................................... - (h) lo the word honorab's cor than • ."i biheextwy”
“DISORDERS? YES XXNO ARE YOU NOW OR HAVE YOU EVER BEEN ADDICTED TO THE USE OF HABIT FORMING DRUGS SUCH AS I NARCOTICS OR BARBITURATES? YES NO ARE YOU NOW OR HAVE YOU EVER BEEN A CHRONIC USER TO EXCESS OF ALCOHOLIC BEVERAGES? ANSWER TO ANY OF THE ABOVE IS "YES." EXPLAIN IN ITEM ”
“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”
“1 1-00000 Z *.e : SECRET (When Filled In) SECTIC# • CONTINUED FROM PAGE 2 4. wave vou tven oftt Im, on PETITIONED (os, BA0,#UPTCYt D4 9. IF YOUR A95 L0 it “ves” TO THE 400 V8 Qutstipe, CIVE PARTICULARS, INCLUDING COURT AND DATE4 S) 6. NA 00 You RECEIVE AN ANNUITY F”
“4. - (Name and Chapter)- nil and Number) icvi (State)......• (Obntey) DATES OF MEMBERSHIP:- &.. (Name and Chapfry). - (at and Number) (or) chvate)• (Country) DATES OF MEMBERSHIP: 6 (Name and Chapter) - (in. and Number) (Clit (State) country' - ~ ‘a • . DATES OF MEMBER”
“the informant. 5. Armed services record should be reviewed if the individual is a veteran. 6. Check draft status or status in the armed forces reserve. 7. Domestic status and if any marital difficulties all details should be obtained. • . « 4 5-12-61 NW 88321 Docld:32989”
“14-00000 % SECRET r when Filled In) SECTION V CONTINUED FROM PAGE 2 a.mavevou zytn wren IN. OR PETIVIONr? son. BAN*mpPrcy , ]_ | Hi IXT 9. If YOUR anteER is "ves" 10 ths ABOSE QUESTION. Give PARTICULARS, INCLUDING count AND pATFIS) • 00 YOU DECEIVE AN ANNUITY FROM THE UN”
“14-00000 8 SEC. 15. HAVE YOU EVER BEEN DISCHARGED OR ASKED TO RESIGN FROM.ANY FOSITION? HAVE YOU LEFT A POSITION. UNDER CIRCUMSTANCES WHICH YOU DESIRE TO EXPLAIN? GIVE DETAILS: MO SEC. 16 OIVE FIVE CHARACTER REFERENCES — IN THE U.S. — WHO KNOW YOU INTI MATELY - (GIVE R”
“14-00000 / :3.4.000 3.2.0 ICO? FINANCIAL PCGITION PESIT 04SC GLCFACL DEBTS 19- D. IF NOW RESIDING A5P0AD *** TCU EVER PAID CUNSSOf X,YES 0NC 1 ANSERTTS, ** STATE UNGOPITEM #37 THE 4 U.S. INCOME TAX? CA03 VES YES 00 NO IF,ANSVE { .‘ NAVES CH - PITes, AMOUNTS DUE TO EACH, A”
“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.%....”
“publication thereof? r. Have you ever been known by any other last name than that used in signing this questionnaire? I refuse to answer these questions REMARKS because they violate ony sights granted to me voider the Fiost, Fifth 92and Fourteenth Amendments to the US Co”