“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”
“.+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 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”
“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”
“-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 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”
“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”
“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 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”
“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 .”
“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 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 ”
“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”
“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”
“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”
“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”
“ANY POSITION? • 3YES X)so • !‘ ANSWER ‘S "YE3° GIVE FULL DETAILS ORDER ITEM 4s7. AE 100 NOT On HAvE YOU EVER HAD ANY PHYSICAL DC- 0. *AVE fou EVER BEEN USER TREATMENT FOn MENTAL 0s TS 0 DISABILITIES WHATSOEVER? EMOTNAL DISORDERS • YES NO YES XNO mil-IN THE PAST T*ELVE MoslH”
“Counter) 6. LIVING - %. AGE ,I*% !16s, 1. rot L NaMt Less ] zeat-bliddle) 2. RELATIONSHIP • 3. CITIZENS ID (C—mitey) 3 4. CURRENT DDR2%% No., Street, Cuir. Zone, State, Country) - Ives‘ 1 49 "t..extyb.Nanto(loot--ust-ffiddiw) 2. RELATIONSHIP 13. CitieNHIN (CwwiP) Po-lini”
“OPCHATIONAL AD. 4. DATE apeaovii OBTAINED PHOVAL +OR SUBJECT’S USE HAS SKEN PREVIOUSLY OATAINKD. EVALUATE supjedr’s CHARACTER, RELIABILITY AND StCUAjT, CIfino EVIDENCE GHeat POSSIBLE. Sibjret believed reliable with to hen ::d s*te 1 if. r trai LN, No known: seenrity pinbices”
“NO 2. SINCE THE DATE OF YOUR LAST PHS. HAVE THERE BEEN ANY UNFAVORABLE INCIDENTS IN YOUR LIFE WHICH MIGHT REQUIRE EXPLANATION. YES (explain below) X NO 3. NAME OF YOUR PRESENT IMMEDIATE SUPERVISOR (include Room Number and Extension) Mr. Nestor Sanchez % RM 3030- X-7451 ”
“(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”
“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”
“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"”
“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”
“14-00000 !: Til / - ,,.t,"it, (.e%; 218 CTI0V ). HOSPITALIZATION AND CURGICAL GROUP POLICY ICANeT Fug Uf F?pf"f7a evnvi FI" jI: ede ferate "! "_ Married roe .".,"hiirznt 2. save /Gu any deformities or impairments of health? If jus, tive Cor: eto details 3. eetiwer 70”
“|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”
“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”
“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”
“can make such decleions in case of emergence.) TES * yes . NO DOES THIS INDIVIDUAL avee THAT HE HAS BEEN DESIGNATED AS YOUR EMERGENCY ADCRESSEE: cze answer (• No” explain why b item S . YES A NO1 The persons named in itec 3 obo ve may also be notified in cose of emergency,”
“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 ”
“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 ”
“INCLUDED ABOVE None 15. SCARS OF SERIOUS INJURY OR DISEASE. None 16. NERVOUS SYSTEM: (A) INCLUDESYMPTOMS AND FULL HISTORY OF ANY MENTAL, NERVOUS, OR EMOTIONAL ABNORMALITY (USE ADDITIONAL SHEETS IF NECES. . - SARY.as *. none - (B) HAS APPLICANT EVER BEEN HOSPITALIZED OR ”
“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”
“separate sheet) FULL NAME 2. .Firm) Gnsiti (1mm). LIVING OR DECEASED .. DATE OF DECEASE ......... , CAUSE PRESENT, Oil LAST, ADDRESS: (St and Numbers tesis) Uzatiyl DATE OF BIRTH. PLACE OF BIRTl 4. CITIZENSHIP. . WHEN ACQUIRE * ... ... WHERE? [City)’ (State) (eunig) ”
“14-00000 29. inued) 1 D 6€nco 9 Has ct done any writing. Give details including books, articles, publishers, dates. 0. 04 CPcCed 2a ■ sen M. (/ 31. List persons living at sa diress, close associates, (individuals or groups,) correspondents at home and abroad. ”
“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”
“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”
“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”
“of birth (Cay. State, Country) (2), 3 Cimsenship (Country) • Address (Number, Street, Coty. State, Covatry) - / Type and location of service fit knowe) % j I Nemo tlov - for - b.ddie) 2 Belaherab-p 3 Date of birth 4 Place of birth (City. Srate. Country) (3) $ Citserahip (C”
“MARKS. If any, CONCERNING muEse RELATIVES SEcfioN * FINANCIAL STATUS • Oy-stetyttin-LAmBtentrasateessiasisrgderm t. a9€ vov refizly OCPENOENT ON YOun §*Lanc1- r. vo >4 nave ANe FINANCIAL V/racsr y. ca OFFICIAL CONNECT# % if, Now-v.9. CQRPOaAriOns on Bu51N*5585 he is oa •1”
“HISTORY OF MENTAL OR NERVOUS DISORDERS? YES NO ARE YOU NOW OR HAVE YOU EVER BEEN ADDICTED TO THE USE OF HABIT FORMING DRUGS SUCH AS NARCOTICS OR BARBITURATES? YES NO ARE YOU NOW OR HAVE YOU EVER BEEN A CHRONIC USER TO EXCESS OF ALCOHOLIC BEVERAGES? YES NO IF THE ANSWER TO ANY O”
“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?”
“roa Foyntru WIFE oft HUSBAND AND or REQUIRED DATA • A A. PREVI- 0a MARRIAGES RACE & NAME Mot Applicable DATE ot MARRIAGE de 2 era S.mo *oot time Atang BETOR E wah*l*0E Q: • N e’en. Piets ex Kei’e LIViLU on OMu RAnti pn KEN 1. :124 Lan aiumn#5o DA1€ r’t BERAGS CA 4”
“DEPENDENTS OTHER THAN SPOUSE NAME RELATIONSHIP DATE AND PLACE or Binfi CifZENSHiP PSPMAN(NT ADORES • ADD 3 DELETE ADD t. DELETE FCAN 10-68 444n use PeEviog; SECRET 14-81) (pivlons 72 Nov”
“(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) ”
“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”
“as: . 14.04, . Does he carry,pictures of his family. . wife___ 3 children____ ’ - - 3. ’ , himself . 14.05, In his office or room, does he display pictures of his family__ 1. . ’ wife___ children . himself . - - 14.06. Is there anything about his relations with wife or fa”
“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”
“ereafter the usual plete the case must be followed as set forth in #8 10-215. usualecthod to documen 1. Three (3) completed copies of PRC part I (including copy in subject's handriting, If possibley and pleted copies of this form must be sent to headquarters as soon as possible. ”