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# STATEMENT OF PERSONAL HISTORYINSTRUCTIONS: Read the certification at the end of this questionnaire before entering the required data. Print or type all answers. All questions and statements must be completed. If the answer is "None," so state. Do not misstate or omit material. If more space is needed, use the Remarks section, item 20, and attach additional sheets if necessary. The information entered hereon is for official use only and will be maintained in confidence.11. | FROM YEAR | TO       | STREET AND NUMBER                        | CITY       | STATE OR COUNTRY || --------- | -------- | ---------------------------------------- | ---------- | ---------------- || APRIL 74  | PRESENT  | 107 Howard Street                        | Dumfries   | Virginia 22026   || MAY 69    | APRIL 74 | 3922 North Forestdale Avenue (DALE CITY) | Woodbridge | Virginia 22191   ||           |          | (((((SEE SUPPLEMENT)))))                 |            |                  ||           |          |                                          |            |                  ||           |          |                                          |            |                  ||           |          |                                          |            |                  ||           |          |                                          |            |                  ||           |          |                                          |            |                  ||           |          |                                          |            |                  ||           |          |                                          |            |                  |16. | NAME AND ADDRESS                                        | TYPE (Social, fraternal, professional, etc.) | OFFICE HELD | MEMBERSHIP FROM-TO || ------------------------------------------------------- | -------------------------------------------- | ----------- | ------------------ || American Legion, POST 139 Wilson Blvd, Arlington, Va.   | SOCIAL                                       | MEMBER      | Jan 1969 Dec 74    || American Legion, POST 162 Horton, Virginia (STREET UNK) | SOCIAL                                       | MEMBER      | Dec 1974 PRESENT   |17. | YES | NO  |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      || --- | --- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ||     | X   | ARE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF THE COMMUNIST PARTY U. S. A., OR ANY COMMUNIST ORGANIZATIONS ANYWHERE?                                                                                                                                                                                                                                                                                                                                                                 ||     | X   | ARE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF A FASCIST ORGANIZATION?                                                                                                                                                                                                                                                                                                                                                                                                                ||     | X   | ARE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF ANY ORGANIZATION, ASSOCIATION, MOVEMENT, GROUP OR COMBINATION OF PERSONS WHICH ADVOCATES THE 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 GOVERNMENT OF THE UNITED STATES BY UNCONSTITUTIONAL MEANS? ||     | X   | ARE 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, ARE OR HAVE BEEN MEMBERS OF ANY OF THE ORGANIZATIONS IDENTIFIED ABOVE?                                                                                                                                                                                                                                                                       ||     | X   | HAVE YOU EVER ENGAGED IN ANY OF THE FOLLOWING ACTIVITIES OF ANY ORGANIZATION OF THE TYPE DESCRIBED ABOVE: CONTRIBUTION(S) TO, ATTENDANCE AT OR PARTICIPATION IN ANY ORGANIZATIONAL, SOCIAL, OR OTHER ACTIVITIES OF SAID ORGANIZATIONS OR OF ANY PROJECTS SPONSORED BY THEM: THE SALE, GIFT OR DIS- TRIBUTION OF ANY WRITTEN, PRINTED, OR OTHER MATTER, PREPARED, REPRODUCED, OR PUBLISHED, BY THEM OR ANY OF THEIR AGENTS OR INSTRUMENTALITIES?                                      |IF "YES" DESCRIBE THE CIRCUMSTANCES. ATTACH ADDITIONAL SHEETS FOR A FULL DETAILED STATEMENT. IF ASSOCIATED WITH ANY OF THE ABOVE ORGANIZATIONS, SPECIFY NATURE AND EXTENT OF ASSOCIATION WITH EACH, INCLUDING OFFICE OR POSITION HELD, ALSO INCLUDE DATES, PLACES, AND CREDENTIALS. NOW OR FORMERLY HELD. IF ASSOCIATIONS HAVE BEEN WITH INDIVIDUALS WHO ARE MEMBERS OF THE ABOVE ORGANIZATIONS, THEN LIST THE INDIVIDUALS AND THE ORGANIZATIONS WITH WHICH THEY WERE OR ARE AFFILIATED.NONE18. HAVE YOU EVER BEEN DETAINED, HELD, ARRESTED, INDICTED OR SUMMONED INTO COURT AS A DEFENDANT IN A CRIMINAL PROCEEDING, OR CONVICTED, FINED, OR IMPRISONED OR PLACED ON PROBATION, OR HAVE YOU EVER BEEN ORDERED TO DEPOSIT BAIL OR COLLATERAL FOR THE VIOLATION OF ANY LAW, POLICE REGULATION OR ORDINANCE (excluding minor traffic violations for which a fine or forfeiture of $15, or less was imposed)? INCLUDE ALL COURT MARTIALS WHILE IN MILITARY SERVICE. ☐ YES ☒ NOIF "YES" LIST THE DATE, THE NATURE OF THE OFFENSE OR VIOLATION, THE NAME AND LOCATION OF THE COURT OR PLACE OF HEARING, AND THE PENALTY IMPOSED OR OTHER DISPOSITION OF EACH CASE.NW 88326 Docld:32255104 Page 6