Francesco/who-killed-jfk huggingface dataset:
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# PERSONAL HISTORY STATEMENTINSTRUCTIONS1.  Answer all questions completely or check appropriate box. If question is not applicable, write "NA". Write "Unknown" 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 DATA1.  FULL NAME (Last Name, First, Middle Initial)    Lakryzalec, Myroslaw Andrew2. AGE   433. SEX   MALE4. HEIGHT   5ft_6inc5. WEIGHT   200 loa6. COLOR OF EYES   hasel7. COLOR OF HAIR   brawn8. TYPE COMPLEXION   Ruddy9. TYPE BUILD   stocky10. SCARS (Type and Location)    NA11. OTHER DISTINGUISHING PHYSICAL FEATURES    Roman noso becaus of desiated septum12. CURRENT ADDRESS (No., Street, City, Zone, State and Country)    526 Valley Dr. Alex. Va.13. PERMANENT ADDRESS (No., Street, City, Zone, State and Country) AND PHONE NO.    3409 Valley Dr. Alex. Va.    TE 6-321814. CURRENT PHONE NO.    MY 5-421215. OFFICE PHONE NO. & EXT.    OX 2157616. LEGAL RESIDENCE (State, Territory or Country)    Manchester N.H.17. NICKNAMES    "Mac_Kurgo18. OTHER NAMES YOU HAVE USED    NA19. INDICATE CIRCUMSTANCES (Including Length of Times) UNDER WHICH YOU HAVE EVER USED THESE NAMES.    childhood nickname for about 50 years20. IF LEGAL CHANGE, GIVE PARTICULARS (Where and by What Authority)## SECTION II POSITION DATA1.  INDICATE THE TYPE OF WORK OR POSITION FOR WHICH YOU ARE APPLYING    General all around photography and photo labatory work2.  INDICATE THE LOWEST ANNUAL ENTRANCE SALARY YOU WILL ACCEPT (This will not be considered for any appointment which involves a higher entrance salary).    $ 6,0003.  DATE AVAILABLE FOR EMPLOYMENT    2-1-614.  INDICATE YOUR WILLINGNESS TO TRAVEL* OCCASIONALLY* FREQUENTLY* CONSTANTLY* OTHER5.  INDICATE YOUR WILLINGNESS TO ACCEPT ASSIGNMENT IN THE FOLLOWING LOCATIONS (Check (X) each item applicable)* WASHINGTON, D.C.* ANYWHERE IN U.S.* CERTAIN LOCATION ONLY (Specify):* OUTSIDE CONTINENTAL U.S.6.  INDICATE WHAT RESERVATIONS YOU WOULD PLACE ON ASSIGNMENTS OUTSIDE THE WASHINGTON. O.C. AREA.    "Mass."FORM 444 (USE PREVIOUS EDITION).11-56
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# SECTION IIICITIZENSHIP1. DATE OF BIRTH4-30-172. PLACE OF BIRTH (City, State, Country)Manchester, N.H.3. PRESENT CITIZENSHIP (Country)4. CITIZENSHIP ACQUIRED BY* BIRTH* MARRIAGE* OTHER (Specify)5. DATE NATURALIZED6. NATURALIZATION CERTIFICATE NO.7. COURT ISSUING NATURALIZATION CERTIFICATENA8. ISSUED AT (City, State, Country)NA9. HAVE YOU HELD PREVIOUS NATIONALITY* YES* NO10. IF YES, GIVE NAME OF COUNTRYNA11. GIVE PARTICULARS CONCERNING PREVIOUS NATIONALITYNA12. HAVE YOU TAKEN STEPS TO CHANGE PRESENT CITIZENSHIP* YES* NO13. GIVE PARTICULARSNA14. IF YOU HAVE APPLIED FOR U.S. CITIZENSHIP, WHAT IS PRESENT STATUS OF YOUR APPLICATION (First Papers, Etc.)?NA15. DATE OF ARRIVAL IN U.S.NA16. PORT OF ENTRYNA17. ON PASSPORT OF WHAT COUNTRYNA18. LAST U.S. VISA (No., Type, Place of Issue)NA19. DATE VISA ISSUEDNA# SECTION IVEDUCATION1. CHECK (X) HIGHEST LEVEL OF EDUCATION ATTAINED* LESS THAN HIGH SCHOOL GRADUATE* OVER TWO YEARS OF COLLEGE, NO DEGREE* HIGH SCHOOL GRADUATE* BACHELOR'S DEGREE* TRADE, BUSINESS, OR COMMERCIAL SCHOOL GRADUATE* GRADUATE STUDY LEADING TO HIGHER DEGREE* TWO YEARS COLLEGE OR LESS* MASTER'S DEGREE* DOCTOR'S DEGREE2. ELEMENTARY SCHOOL1. NAME OF ELEMENTARY SCHOOLBakers-Ville School2. ADDRESS (City, State, Country)Manchester, N.H.3. DATES ATTENDED (From-and-To)1923-19314. GRADUATE* YES* NO3. HIGH SCHOOL1. NAME OF HIGH SCHOOLCentral High2. ADDRESS (City, State, Country)Manchester, N.H.3. DATES ATTENDED (From-and-To)1931-19324. GRADUATE* YES* NO4. COLLEGE OR UNIVERSITY STUDYNAME AND LOCATION OF COLLEGE OR UNIVERSITYSUBJECTMAJORMINOR3. DATES ATTENDEDFROMTODEGREEREC'DDATEREC'DSEM/QTRHOURS(Specify)SECTION IV CONTINUED TO PAGE 1
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SECTION VI## GEOGRAPHIC AREA KNOWLEDGE AND FOREIGN TRAVEL1. LIST BELOW ANY FOREIGN REGIONS OR COUNTRIES IN WHICH YOU HAVE TRAVELLED OR GAINED KNOWLEDGE AS A RESULT OF RESIDENCE, STUDY OR WORK ASSIGNMENT, KNOWLEDGE OF TYPE OF KNOWLEDGE SUCH AS TERRAIN, MAPS, UTILITIES, RAILROADS, INDUSTRIES, POLITICAL PARTIES, ETC.| NAME OF REGION OR COUNTRY | TYPE OF SPECIALIZED KNOWLEDGE | DATES OF RESIDENCE OR TRAVEL | DATES AND PLACE OF STUDY | KNOWLEDGE ACQUIRED BY RESIDENCE | KNOWLEDGE ACQUIRED BY TRAVEL STUDY | KNOWLEDGE ACQUIRED BY WORK ASSIGNMENT || ------------------------- | ----------------------------- | ---------------------------- | ------------------------ | ------------------------------- | ---------------------------------- | ------------------------------------- ||                           |                               |                              |                          |                                 |                                    |                                       ||                           |                               |                              |                          |                                 |                                    |                                       ||                           |                               |                              |                          |                                 |                                    |                                       |2. INDICATE THE PURPOSE OF VISIT, RESIDENCE, OR TRAVEL IN EACH OF THE REGIONS OR COUNTRIES LISTED ABOVE.3. UNITED STATES PASSPORT NUMBER AND EXPIRATION DATE, IF ISSUED.   Special Passport # 18805 Issued 21 July 1950SECTION VII## TYPING AND STENOGRAPHIC SKILLS1. TYPING(wpm)2. SHORTHAND(wpm)3. SHORTHAND SYSTEM USED- CHECK (X) APPROPRIATE ITEM| wpm | wpm |       |              |           |                     || --- | --- | ----- | ------------ | --------- | ------------------- ||     |     | GREGG | SPEEDWRITING | STENOTYPE | OTHER (Specify): NA |2. INDICATE OTHER BUSINESS MACHINES WITH WHICH YOU HAVE HAD OPERATING EXPERIENCE OR TRAINING (Comprometer, Mimeograph, Card Punch, Etc.).NASECTION VIII## SPECIAL QUALIFICATIONS1. LIST ALL HOBBIES AND SPORTS IN WHICH YOU ARE ACTIVE OR HAVE ACTIVELY PARTICIPATED. INDICATE YOUR PROFICIENCY IN EACH.Photography, ice hockey, swimming, football.2. INDICATE ANY SPECIAL QUALIFICATIONS RESULTING FROM EXPERIENCE OR TRAINING WHICH MIGHT FIT YOU FOR A PARTICULAR POSITION OR TYPE OF WORK.All types of photography work and lab work3. EXCLUDING BUSINESS EQUIPMENT OR MACHINES WHICH YOU MAY HAVE LISTED IN ITEM 2, SECTION VII, LIST ANY SPECIAL SKILLS YOU POSSESS RELATING TO OTHER EQUIPMENT AND MACHINES SUCH AS OPERATION OF SHORTWAVE RADIO (Indicate CW speed, sending and receiving), OFFSET PRESS, TURRET LATHE, SCIENTIFIC AND PROFESSIONAL DEVICES.Ozalid mach. automatic photostat. recordax equipment; all types of photo lab equipment including still and motion picture cameras.SECTION VIII CONTINUED TO PAGE 5151
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## SECTION XMILITARY SERVICE1. ARE YOU REGISTERED FOR THE DRAFT? IF   THE DRAFT, UNDER WHAT TRAINING AND   SERVICE ACT AM I REGISTERED?2. SELECTIVE SERVICE CLASSIFI 3. SELECTIVE SERVICE N2.   CATION   N/A4. IF DEFERRED, GIVE REASON5. LOCAL DRAFT BOARD NO. OR DESIGNATION AND ADDRESS   N/A1. CURRENT AND PAST ORGANIZATIONAL MEMBERSHIP   CHECK (X) AS   APPROPRIATE ARMY NAVY MARINE COAST MERCHANT NATIONAL AIR NAT'L. FOREIGN ORGAN, OR MIL.   GUARD GUARD SERVICE   HAVE SERVED=   NOW SERVING =2. BRANCH OR CORPS OF ABOVE CHECKED ORGANIZATIONS3. DATE SEPARATED FROM EXTENDED ACTIVE DUTY (Past service 4. TOTAL LENGTH OF EXTENDED ACTIVE DUTY IN U.S. ARMED   only) N/A FORCES(Past and current service)5. DATE ENTERED PAST SERVICE CURRENT SERVICE 6. TOTAL LENGTH OF ACTIVE DUTY IN FOREIGN MILITARY OR-   ACTIVE DUTY 2-25-41 GANIZATION7. RANK, GRADE OR PAST SERVICE CURRENT SERVICE 8. SERVICE. SERIAL OR FILE NUMBER(If now serving, provide cur-   RATE rent number)   R1 2014059. PRIMARY MILITARY OCCUPATIONAL PAST SERVICE CURRENT SERVICE   SPECIALTY (Number of Designator) AND TITLE Asst. Chief of Staff10. SECONDARY MIL. OCCUPATIONAL PAST SERVICE CURRENT SERVICE    SPECIALTY (Number of Designator) AND TITLE11. BRIEF DESCRIPTION OF MILITARY DUTIES (Indicate whether applicable to past of current service)    Intelligence photography, General FIO work for the past 11 years.    I have been involved in intelligence photography for the    Asst. Chief of Staff Intell12. CHECK (X) TYPE OF SEPARATION FROM ACTIVE DUTY    HONORABLE DISCHARGE DET. PENDING COURT    OF SERVICE MARTIAL    RELEASE TO ACTIVE DUTY RET. PENDING    RETIREMENT FOR AGE PHYSICAL DISABILITY    UNIQUE HARDSHIPS    OTHER:    REGULAR RESERVE (Including the National and Air Guard)    OTHER (Including AUS)13. CHECK (X) COMPONENT IN WHICH YOU SERVED    RESERVE STATUS NATIONAL GUARD AND ROTC STATUS1. DO YOU NOW HAVE YES 2. ARE YOU NOW A MEMBER OF YES 3. ARE YOU NOW A MEMBER OF YES   RESERVE STATUS THE NAT'L GUARD THE ROTC   NO NO NO4. IF YOU HAVE ANSWERED "YES" TO ITEMS 1, 2 OR 3 ABOVE, CHECK COMPONENT MEMBERSHIP BELOW   ARMY NAVY MARINE COAST GUARD NAVY ROTC ARMY ROTC AIR FORCE ROTC   AIR NAT'L. GUARD AIR FORCE ROTC DER.5. CURRENT RANK, GRADE OR 6. DATE OF APPOINTMENT IN CURRENT 7. EXPIRATION DATE OF CURRENT RESERVE OBLIGA-   RATE RANK TION8. CHECK (X) CURRENT RESERVE CATEGORY READY RESERVE STANDBY(Active) STANDBY(Inactive) RETIRED9. PRIMARY MILITARY OCCUPATIONAL SPECIALTY (Number or Desig- 10. SECONDARY MILITARY OCCUPATIONAL SPECIALTY (Number   nator) AND TITLE and Desig)11. BRIEF DESCRIPTION OF MILITARY DESIRED DUTIES12. ARE YOU CURRENTLY ASSIGNED OR ATTACHED YES 13. IF YOU HAVE ANSWERED "YES" TO ITEM 12, GIVE UNIT OR AGENCY    TO A RESERVE, NAT'L. GUARD OR ROTC TRAIN- AND ADDRESS    ING UNIT14. HAVE YOU A MILITARY MOBILIZATION ASSIGN- YES 15. IF YOU HAVE ANSWERED "YES" TO ITEM 14, GIVE UNIT OR AGENCY    MENT? AND ADDRESS16. INDICATE TOTAL MILITARY SERVICE YEARS MONTHS 17. WHERE ARE YOUR SERVICE RECORDS KEPT?    FOR LONGEVITY PURPOSES INCLUDING 23 Adjt. General Office Wash D.C.    ACTIVE AND INACTIVE DUTY(155
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# FINANCIAL STATUS## SECTION XI*   ARE YOU ENTIRELY DEPENDENT ON YOUR SALARY?NA*   BANKING INSTITUTIONS WITH WHICH YOU HAVE ACCOUNTSFirst and merches.National Bank of Richmont Va.Credit UnionPentagon Wash. D.C.The Amoskeag National BankManchester, N.H.*   HAVE YOU EVER BEEN IN BANKRUPTCY?*   IF YOUR ANSWER IS "YES" TO THE ABOVE, GIVE PARTICULARS, INCLUDING COURT AND DATENA*   GIVE THREE CREDIT REFERENCES IN THE UNITED STATESADDRESS (No., Street, City, State)Lauer & Co.Wash. D.C.Foodward & LothropJash. D.C.Julius Garfinkel*   DO YOU RECEIVE AN ANNUITY FROM THE UNITED STATES OR DISTRICT OF COLUMBIA GOVERNMENT UNDER ANY RETIREMENT ACT, PENSION, OR COMPENSATION FOR MILITARY OR NAVAL SERVICE?*   IF YOUR ANSWER IS "YES" TO THE ABOVE QUESTION, GIVE COMPLETE DETAILSRetirement from the United States Army 20 years*   DO YOU HAVE ANY FINANCIAL INTEREST IN, OR OFFICIAL CONNECTION WITH MONIES U.S. CORPORATIONS OR BUSINESSES HAVING SUBSTANTIAL FOREIGN INTERESTS?SECTION XIIMARITAL STATUS*   PRESENT STATUS (Single, Married, Widowed, Separated, Divorced, or Annulled) SPECIFY:*   STATE DATE, PLACE, AND REASONS FOR ALL SEPARATIONS, DIVORCES OR ANNULMENTSNAWIFE, HUSBAND If you have been married more than once - including annulments - use a separate sheet for former wife or OR FIANCE: husband giving data required below for all previous marriages. If marriage contemplated, fill in appropriate information for fiance.EileenElizabethSuckeMcKenzie*   STATE ANY OTHER NAMES EVER USED:    INDICATE CIRCUMSTANCES (including length of time) UNDER WHICH ANY OF THESE NAMES WERE USED. IF LEGAL CHANGE GIVE PARTICULARS. (Where and on what authority) USE EXTRA SPACE PROVIDED ON PAGE 10 OF THIS FORM TO RECORD THIS INFORMATION.Dimples*   DATE OF MARRIAGE:    PLACE OF MARRIAGE (No., Street, City, State, Country)Nov. 15, 1958Arlington Va.152 Bay State Rd., Worcester, Mass.*   IS LIVING*   DATE OF DEATH*   CAUSE OF DEATHNA*   CURRENT ADDRESS (Give last address if deceased):    Alex., Va.10-23-25Worcester, Mass.SECTION XII CONTINUED TO PAGE 10793
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1-718. DATE OF ENTRY191413. PLACE OF ENTRYNew York14. FORMER CITIZENSHIP(S) ACQUIREDUSA16. OCCUPATIONRetired17. DETAILS OF OTHER GOVERNMENT SERVICE, U.S. OR FOREIGNNA20. COUNTRYUSA10MOTION CONTINUED12. DATE OF ENTRYNA13. PLACE OF ENTRYNA14. FORMER CITIZENSHIP(S)NAACQUIRED16. OCCUPATIONHousewife21. EMPLOYER'S OR BUSINESS ADDRESS OF SELF-EMPLOYEDNA22. DATES OF MILITARY SERVICE (From and To)NA23. BRANCH OF SERVICENA24. IS COUNTRY WITH MILITARY SERVICE AFFILIATEDNA25. DETAILS OF OTHER SERVICE U.S. OR FOREIGNNASECTION VIII1. PROVIDE THE FOLLOWING INFORMATION FOR ALL CHILDREN AND DEPENDENTS| RELATIONSHIP | DATE AND PLACE OF BIRTH | CITIZENSHIP | ADDRESS                  || ------------ | ----------------------- | ----------- | ------------------------ || son          | 1-30-60 / Mash, AZ      | USA         | 5265 Valley Dr.          || daughter     | 2-3-31 / Mash, AZ       | USA         | 5265 Valley Dr.          || father       | 11-11-06 / Austria      | USA         | 92 Vinton St. Manchester ||              |                         |             |                          |2. NUMBER OF CHILDREN (Adult(s) and or adult(s) children AND ARE UNMARRIED, UNDER 21 YRS OF AGE, AND NOT SELF-SUPPORTING.SECTION XIV1. FULL NAME (Last-First-Middle)Lakersien, Asyl2. LIVINGCN3. DATE OF DEATHNA4. CAUSE OF DEATHNA9. STATE OTHER NAMES HE HAS USEDBill, WilliamINDICATE CIRCUMSTANCES (Including length of time) UNDER WHICH NAME HAS EVER USED THESE NAMES. IF LEGAL CHANGE, GIVE PARTICULARS (date and by what authority). USE EXTRA SPACE PROVIDED ON PAGE 19 OF THIS FORM TO RECORD THIS INFORMATION.8. CURRENT ADDRESS (Give last address: street, city, state, country)92 Vinton Street Manchester7. DATE OF BIRTH11-11-268. PLACE OF BIRTHROSSESS10. IF BORN OUTSIDE U.S. DATE OF ENTRY191411. FORMER CITIZENSHIP(S)USA
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# SECTION AV MOTHER1. FULL NAME (Last-First-Middle)   Makowine, Justinn5. STATE OTHER NAMES SHE HAS USED   NA6. CURRENT ADDRESS GIVE LAST ADDRESS, IF DECEASED (No., Street, City, State, Country)   State Hospital Concord. Mass.7. DATE OF BIRTH   18968. PLACE OF BIRTH (City, State, Country)   Austria, Sobotmar10. IF BORN OUTSIDE U.S.-DATE OF ENTRY    191211. PLACE OF ENTRY    New York12. FORMER CITIZENSHIP(S) (Countries)    Austria13. DATE, U.S. CITIZENSHIPACQUIRED14. WHERE ACQUIRED (City, State, Country)15. OCCUPATION    Housewife16. PRESENT EMPLOYER (Give last employer, if neither is deceased or unemployed)NA17. EMPLOYER'S BUSINESS ADDRESS OR MOTHER'S BUSINESS ADDRESS IF SELF EMPLOYEDNA18. DATES OF MILITARY SERVICE (From-and-To)NA19. BRANCH OF SERVICENA20. COUNTRYNA21. DETAILS OF OTHER GOVERNMENT SERVICE, U.S. OR FOREIGNNA# SECTION XVI BROTHERS AND SISTERS (Including-Half, Step-and Adopted Brothers and Sisters)1. FULL NAME (Last-First-Middle)   Hacker, John4. CURRENT ADDRESS (No., Street, City, Zone, State, Country)   512 113 star st. loulenslahr. 7.1. FULL NAME (Last-First-Middle)   Londensla er, OLa4. CURRENT ADDRESS (No., Street, City, Zone, State, Country)   92 Vinton st.Manchester. #.1. FULL NAME (Last-First-Middle)   Laksymiec, wagyl4. CURRENT ADDRESS (No., Street, City, Zone, State, Country)   506 co. Willow st.1. FULL NAME (Last-First-Middle)4. CURRENT ADDRESS (No., Street, City, Zone, State, Country)1. FULL NAME (Last-First-Middle)4. CURRENT ADDRESS (No., Street, City, Zone, State, Country)1. FULL NAME (Last-First-Middle)4. CURRENT ADDRESS (No., Street, City, Zone, State, Country)1. FULL NAME (Last-First-Middle)4. CURRENT ADDRESS (No., Street, City, Zone, State, Country)2. RELATIONSHIP   brother3. CITIZENSHIP (Country)   USA   9. LIVING   yes   no6. AGE   432. RELATIONSHIP   sister3. CITIZENSHIP (Country)   USA   9. LIVING   yes   no6. AGE   522. RELATIONSHIP   brother3. CITIZENSHIP (Country)   USA   9. LIVING   yes   no6. AGE   732. RELATIONSHIP3. CITIZENSHIP (Country)   9. LIVING   yes   no6. AGE2. RELATIONSHIP3. CITIZENSHIP (Country)   9. LIVING   yes   no6. AGE2. RELATIONSHIP3. CITIZENSHIP (Country)   9. LIVING   yes   no6. AGE2. RELATIONSHIP3. CITIZENSHIP (Country)   9. LIVING   yes   no6. AGE--11-158
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SECTION XVII1. FULL NAME (Last-First-Middle)Burke, Thomas William3. STATE OTHER NAMES HE HAS USEDTom, Conroy6. CURRENT OR LAST ADDRESS (No., Street, City, State, Country)152 Bay State Rd., Zone 0207. DATE OF BIRTH12-12-948. PLACE OF BIRTH (City, State, Country)Lowell, Mass13. FORMER CITIZENSHIP (Countries)NA15. OCCUPATIONretired1. LIVINGYES3. DATE OF DEATHNAINDICATE CIRCUMSTANCES (Including length of times AND by what authority, USE EXTRA SPACE, PROVIDED ON PAGE 15 OF THIS FORM TO RECORD THIS INFORMATION9. CITIZENSHIPUSA14. WHERE ACQUIRED (City, State, Country)NA16. PRESENT EMPLOYER (Give last employer, if Father-in-Law is deceased or unemployed)NASECTION XVIII1. FULL NAME (Last-First-Middle)Burke, Eileen Veronica5. STATE OTHER NAMES SHE HAS USEDNA6. CURRENT OR LAST ADDRESS (No., Street, City, State, Country)152 Bay State Rd., 0207. DATE OF BIRTHAug. 7,18969. IF BORN OUTSIDE U.S., DATE OF ENTRY191114. FORMER CITIZENSHIP (Countries)Ireland16. OCCUPATIONNAMOTHER-IN-LAW2. LIVINGYES3. DATE OF DEATHNA4. CAUSE OF DEATHNAINDICATE CIRCUMSTANCES (Including length of times UNDER WHICH SHE HAS USED THESE NAMES, IF LEGAL CHANGE, GIVE PARTICULARS: USE EXTRA SPACE PROVIDED ON PAGE 15 OF THIS FORM TO RECORD THIS INFORMATION.8. PLACE OF BIRTH (City, State, Country)Zillarney Ireland11. PLACE OF ENTRYBoston, Mass15. DATE U.S. CITIZENSHIP ACQUIRED2-2-299. CITIZENSHIPyes USA14. WHERE ACQUIRED (City, State, Country)Worcester, Mass.19. PRESENT EMPLOYER (Give last employer, if Mother-in-Law is deceased or unemployed)NASECTION XIX RELATIVES BY BLOOD, MARRIAGE OR ADOPTION WHO EITHER (1) LIVE ABROAD, (2) ARE NOT U.S. CITIZENS OR (3) WORK FOR A FOREIGN GOVERNMENT1. FULL NAME (Last-First-Middle)2. AGE4. ADDRESS OR COUNTRY IN WHICH RELATIVE RESIDES5. EMPLOYED BY6. RELATIONSHIP8. DATE OF LAST CONTACT9. AGE3. CITIZENSHIP (Country)7. FREQUENCY OF CONTACT1. FULL NAME (Last-First-Middle)2. AGE4. ADDRESS OR COUNTRY IN WHICH RELATIVE RESIDES5. EMPLOYED BY6. RELATIONSHIP8. DATE OF LAST CONTACT9. AGE3. CITIZENSHIP (Country)7. FREQUENCY OF CONTACT1. FULL NAME (Last-First-Middle)2. AGE4. ADDRESS OR COUNTRY IN WHICH RELATIVE RESIDES5. EMPLOYED BY6. RELATIONSHIP8. DATE OF LAST CONTACT9. AGE3. CITIZENSHIP (Country)7. FREQUENCY OF CONTACTSECTION XIX (CONTINUED TO PAGE 18)157
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SECTION XXII CLUBS SOCIETIES, AND OTHER ORGANIZATIONSNOTE: List names and addresses of all clubs, societies, professional societies, employee groups or organizations of any kind(Include membership in, or support of, any organization having headquarters or branch in a foreign country to which you belong or have belonged)| NAME AND CHAPTER | ADDRESS (Number, Street, City, State, Country) | DATES OF MEMBERSHIP || ---------------- | ---------------------------------------------- | ------------------- || N.C.O.           | Ft. Myer Va.                                   | 1947 1961           || American Leg.    | Manchester N.H.                                | 1945 1947           || Ukrianan Club    | Manchester N.H.                                | 1938 1942           |SECTION XXIII RESIDENCES FOR THE PAST 15 YEARS| ADDRESS - LAST RESIDENCE FIRST (Number, Street, City, State, Country) | INCLUSIVE DATES || --------------------------------------------------------------------- | --------------- || 3268 Valley Dr. Alex. Va.                                             | 1958 1961       || United States Aray                                                    | 1941 1953       |
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# SECTION XXIVADDITIONAL INFORMATION1. DO YOU ADVOCATE OR HAVE YOU EVER ADVOCATED, OR ARE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF, OR ASSOCIATED WITH ANY INDIVIDUAL, PARTY, ORGANIZATION, MOVEMENT, GROUP OR COMBINATION OF PERSONS WHICH ADVOCATES OR TEACHES THE OVERTHROW OF THE GOVERNMENT OF THE UNITED STATES BY FORCE OR VIOLENCE OR BY ANY UNCONSTITUTIONAL MEANS, OR SEEK TO ALTER THE FORM OF GOVERNMENT OF THE UNITED STATES, BY FORCE OR VIOLENCE TO DENY PERSONS THEIR RIGHTS UNDER THE CONSTITUTION OF THE UNITED STATES?2. IF YOU HAVE ANSWERED "YES" TO THE ABOVE QUESTION, EXPLAINNA3. DO YOU USE OR HAVE YOU EVER USED INTOXICANTS!YESNO4. IF SO, TO WHAT EXTENT?Very moderately5. DO YOU USE OR HAVE YOU EVER USED NARCOTICSYESNO6. IF SO, TO WHAT EXTENT?NA7. HAVE YOU EVER BEEN A MEMBER OF, OR SUPPORTED, OR HAD ANY CONNECTIONS WITH A FOREIGN INTELLIGENCE ORGANIZATION OR ITS ACTIVITIES?YESNOIF ANSWER IS "YES", GIVE COMPLETE DETAILS.8. LIST BELOW THE NAMES OF GOVERNMENT DEPARTMENTS, AGENCIES OR OFFICES TO WHICH YOU HAVE APPLIED FOR EMPLOYMENT SINCE 1940Asst. Chief Staff Intel. Pentagon Wash. D.C.9. IF TO YOUR KNOWLEDGE, ANY OF THE ABOVE HAVE CONDUCTED AN INVESTIGATION OF YOU, INDICATE THE NAME OF THE AGENCY AND THE APPROXIMATE DATE OF THE INVESTIGATION.Asst. Chief of Staff for Intell date of investagation 1950NOTE SPECIAL: If your answer is "YES" to the following Questions 10, 11 or 12, provide the information requested for each question on a separate, signed sheet and attach the sheet to this form in a sealed envelope.INSTRUCTIONS10. HAVE YOU, OR TO YOUR KNOWLEDGE HAS YOUR SPOUSE, EVER BEEN DETAINED, ARRESTED, INDICTED OR CONVICTED FOR ANY VIOLATION OF THE LAW (OTHER THAN A MINOR TRAFFIC VIOLATION) IN THE UNITED STATES OR ABROAD?YESNOIF SO, STATE NAME OF COURT, CITY, STATE, COUNTRY, DATE, NATURE OF OFFENSE AND DISPOSITION OF CASE IN ACCORDANCE WITH THE SPECIAL INSTRUCTION ABOVE.11. HAVE YOU EVER BEEN ARRESTED, COURT-MARTIALED OR OTHERWISE PUNISHED UNDER MILITARY LAW OR REGULATION? IF SO, DESCRIBE INCIDENT(S) AND PROVIDE DATE(S) OF OCCURRENCE ON SEPARATE SHEET IN ACCORDANCE WITH SPECIAL INSTRUCTIONS ABOVE.YESNO12. ARE THERE ANY UNFAVORABLE INCIDENTS IN YOUR LIFE, NOT MENTIONED ABOVE, WHICH MAY BE DISCOVERED IN SUBSEQUENT INVESTIGATION, WHETHER YOU WERE DIRECTLY INVOLVED OR NOT, WHICH MIGHT REQUIRE EXPLANATION? IF SO, DESCRIBE INCIDENT(S) AND PROVIDE DATE(S) OF OCCURRENCE ON SEPARATE SHEET IN ACCORDANCE WITH SPECIAL INSTRUCTIONS ABOVE.YESNO# SECTION XXVPERSON TO BE NOTIFIED IN CASE OF EMERGENCY1. NAME (First-Middle-Last)Eileen Elizabeth Maksymiec2. RELATIONSHIPwife3. HOME ADDRESS (No. Street, City, Zone, State, Country)4035 Holley Dr. Clay, Va4. HOME PHONE NO.TE 6-82135. BUSINESS ADDRESS (No. Street, City, Zone, State, Country) - INDICATE NAME OF FIRM OR EMPLOYER, IF APPLICABLENA6. BUSINESS PHONE NO. & EXT.NA7. IN CASE OF EMERGENCY, OTHER CLOSE RELATIVES (Spouse, Mother, Father) MAY ALSO BE NOTIFIED. IF SUCH NOTIFICATION IS NOT DESIRABLE, BECAUSE OF HEALTH OR OTHER REASONS, PLEASE SO STATE.Mr. Masyl Maksymiec 92 Vinton St. Manchester N.H.