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# STATEMENTINSTRUCTIONS: 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 fact since the statements made herein are subject to verification. 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.1. (Print) FIRST NAME-MIDDLE NAME--MAIDEN NAME (If any)-LAST NAME*   MR.*   MRS.*   MISSROBERT (NMN) SCHEER2. STATUS*   CIVILIAN*   MILITARY ON ACTIVE DUTY3.  ALIAS(ES). NICKNAME(S). OR CHANGES IN NAME (Other than by marriage)None4. PERMANENT MAILING ADDRESS2828 Milvia St., Berkeley, California5. DATE OF BIRTH (Day, month, year)4 April 1936PLACE OF BIRTH (City, County, State, and Country)Bronx, New York, New York, USAPLACE CERTIFICATE RECORDEDBronx, New YorkRACECaucHEIGHT70"WEIGHT180COLOR OF EYESBrownCOLOR OF HAIRBrownSCARS, PHYSICAL DEFECTS, DISTINGUISHING MARKSNone6. DO YOU HAVE A HISTORY OF MENTAL OR NERVOUS DISORDERS? ☐ YES XX 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 XX NO IF THE ANSWER TO ANY OF THE ABOVE IS "YES." EXPLAIN IN ITEM 20.7. U. S. CITIZEN*   YES*   NONATIVEIF NATURALIZED, CERTIFICATE NO.IF DERIVED. PARENTS CERTIFICATE NO(S).DATE, PLACE, AND COURTALIENREGISTRATION NONATIVE COUNTRYDATE AND PORT OF ENTRYDO YOU INTEND TO BECOME A U. S. CITIZEN?*   YES*   NO8. MILITARY SERVICEARE YOU PRESENTLY ON ACTIVE DUTY IN THE U. S. ARMED FORCES DRAWING FULL PAY? ☐ YES ☐ NO IF "YES," COMPLETE THE FOLLOWING:GRADE AND SERVICE NO.SERVICE AND COMPONENTORGANIZATION AND STATIONDATE CURRENT ACTIVE SERVICE STARTEDARE YOU PRESENTLY A MEMBER OF A U. S. RESERVE OR NATIONAL GUARD ORGANIZATION? ☐ YES ☑ NO IF YES. COMPLETE THE FOLLOWING:GRADE AND SERVICE NO.SERVICE AND COMPONENTORGANIZATION AND STATION OR UNIT AND LOCATIONHAVE YOU PREVIOUSLY SERVED TOURS OF EXTENDED ACTIVE DUTY, DRAWING FULL PAY, FROM WHICH YOU WERE DISCHARGED OR SEPARATED TO CIVILIAN STATUS? ☐ YES ☑ NO IF "YES." COMPLETE THE FOLLOWING:| COUNTRY | SERVICE | COMPONENT         | FROM (Date) | TO (Date) | TYPE DISCHARGES OR SEPARATIONS-GRADE AND SERVICE NO. || ------- | ------- | ----------------- | ----------- | --------- | ---------------------------------------------------- ||         |         | ЗАКОИ К HUAWEHIDU |             |           |                                                      |9. EDUCATION (Account for all civilian schools and military academies. Do not include service schools)| MONTH AND YEAR  | NAME AND LOCATION OF SCHOOL                  | GRADUATE | DEGREE   || --------------- | -------------------------------------------- | -------- | -------- ||                 |                                              | YES      | NO       || Sep 49 - Jun 53 | Christopher Columbus High School, Bronx, NTY | X        | Academic || Sep 53 - Jun 55 | Queens College, Queens, New York             |          | X        || Sep 55 - Jun 58 | The City College of New York, New York, N.Y. | X        | B.A.     || Sep 59 - Jun 59 | Syracuse University, Syracuse, New York      |          | X        || Sep 60 - Jun 61 | University of Calif., Berkeley               |          |          |10. FAMILY (List in order: parents, spouse, guardians, stepparents, foster parents, parents-in-law, former spouse(s) (if divorced give date and place), children, brothers and sisters, even though deceased. Include any others you resided with or with whom a close relationship existed or exists. If the person is not a U. S. citizen by birth, give date and port of entry, alien registration number, naturalization certificate number and place of issuance.)| RELATION AND NAME    | DATE AND PLACE OF BIRTH | PRESENT ADDRESS, IF LIVING | U. S. CITIZEN |     || -------------------- | ----------------------- | -------------------------- | ------------- | --- ||                      |                         |                            | YES           | NO  || FATHER               | 25 May 1898             | Deceased                   | X             |     || Fred Scheer          | Germany                 |                            |               |     || MOTHER (Maiden name) | 24 Apr 1900             | 2860 Bronx Park East       |               | X   || Ida Kuran            |                         | Bronx, New York            |               |     || SPOUSE (Maiden name) | Feb 1942                | 2828 Milvia Street         | X             |     || Anne Weills          | Eureka, Calif.          | Berkeley, Calif.           |               |     || OTHER (Specify)      |                         |                            |               |     || None                 |                         |                            |               |     |