HAVE BEEN MEMBERS OF ANY OF THE ORGANIZATIONS IDENTIFIED ABOVE? ’ j OR EMPLOYEE?ĪRE YOU NOV/ ASSOCIATING WITH, OR HAVE YOU ASSOCIATED WITH ANY INDIVIDUALS. THE UNITED STATES BY UNCONSTITUTIONAL MEANS?ĪRE YOU NOW OR HAVE YOU EVER BEEN AFFILIATED OR ASSOCIATED WITH ANY ORGANIZATION OF THE TYPE DESCRIBED ABOVE AS AN AGENT. OR WHICH SEEKS TO ALTER THE FORM OF GOVERNMENT CF OR VIOLENCE TO DEMY OTHER PERSONS THEIR RIGHTS UNDER THE CONSTITUTION OF THE UNITED STATES. OR WHICH HAS ADOPTED THE POLICY OFADVOCATING OR APPROVING THE COMMISSION CF ACTS OF FORCE OVERTHREW OF OUR CONSTITUTIONAL FORM OF GOVERNMENT. GHOUP OR COMBINATION OF PERSONS Y.'HICH ADVOCATES THE OR ANY COMMUHS5T ORGANIZATIONS ANYWHERE?ĪRE YOU NOV/ CR HAVE YOU EVER BEEN A MEMBER OF A FASCIST ORGANIZATION? - ĪRE YOU HOW OR HAVE YOU EVER BEEN K MEMBER OF ANY ORGANIZATION. LIST ALL' RESIDENCES FfiOftl 1 JAMUAilV 1037'ĪRE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF THE COMMUNIST PARTY U. OID ANY OF THE ABOVE E/APLOYMENTS REQUIRE A SECURITY CLEARANCE? □ YES 'jr^r NO'-'wDO YOU HAVEĪNY FOREIGN PROPERTY OR BUSINESS CONNECTIONS, OR HAVE YOU EVER BEEip at the end of thh questionnaire before Jul 196 ?j 03 Angeles Times Printing Co.įeb 1966 J A7 o Robinsons Department Str33 Include any others you resided with or with whom a cl os/ĮMPLOYMENT (S/ioiv every employment you have had and all periods of unemployment)įeb I960 Marj*s Diner Los Angeles, California Fftt’llY ( List in order given, parents, spouse, guardians, stepparents, foster parents, parents-in-law, former spouss(s) ( if divotĪnd place), children, brothers and sisters, even though deceased. Los Angeles City College, Los ingeles, Calif 'ġ0. Luther Burbank- Junior High" School, Los Ansrel.es Xīenjamin Franklin High School, Los Angeles X_ Do not include service schools)ĭele van Drive Eliinentry School. Srmy, 2nd Armd Cav Hq 2nd Armored Cavalry Regiment SE Tl E Wa te) I TO ( Da f e) [ TYPE "DISCHARGES OR SEPARAT IONS - GRADE AND SERVICE NO.ĮDUCATION (Account /or all civilian schools and military academics. SERVICE AND COMPONENT ORGANIZATION AND STATION DATE CURRENT ACTIVE ARMED FORCES DRAWING FULL PAY? EE3 YES □ NO IF “YES,“ COMPLETE THE FOLLOWING: AND COURT !ĪRE YOU PRESENTLY ON ACTIVE DUTY IN THE U. ' IF DERIVED, PARENTS' CERTIFICATE NO(S). NARCOTICS OR BARBITURATES? Q YES HO ARE YOU HOW OR HAVE YOU EVER BEEN A CHRONIC USER TO EXCES5 OF ALCOHOLIC BEVERAGES? □ YES O HO lr THEĪNSWER TO ANY OF THE ABO V E IS “YES." EXPLAIN IN ITEM 20. DO YOU HAVE A HISTORY'S?, MENTAL OR'NERVOUS DISORDERS? □ YES HO ARE YOU HOW OR HAVE YOU EVER BEEN ADDICTED TO THE USE OF HABIT FORMING DRUGS SUCH AS j SCARS, PHYSICAL DEFECTS, DtST IHGU5SHIHG MARKSħ5 n ' vfy ' [ 165 ' Bm Brh Birthmark on Et? thigh ? Scare on Br&g 0 Ħ. Los Angel.eso Log Angel.es, California L on Angeles Count y _ PLACE OF BIRTH (City, County, State, ana Country) OR-CHANGES IN NAME /Of 7ior than by marriage) I^JPrint) FIRST NAME-MIDDLE NAME-MAIDEN HAMlt (// any)“LAST NAMEģ. The information entered hereon 13 for official use only and will be maintained in confidence. If more space bneeded, use the Rcmarlro cection, item 20, and. Do not misstate or omit materialįo/,:t sivtce the statements made herein are subject to verification. All^uestions and state^^rts must be completed. INSTRUCTIONS : : Read the cer^^HRion at the end of this questionnaire beforc^^Jcring the required data.
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