(foa-tovt7-10075 - ts . “ SUPPLEMENTAL PERSONAL HISTORY STATEMENT SECTION 1. INSTRUCTIONS Submit in duplicate. Answer all questions completely. If question does not apply, write “NA.” Write “UNKNOWN?” only if you do not know-the answer and it cannot be obtained from personal records. If additional space is required use extra pages the same size as this page and sign each such page. Reference each continued item by “section and item number to which it relates. f. FULL NAME (fast- first-middle ) 2-DATE OF BIRTH] 3. PLACE OF BIRTH (City, State ,Country}i4: SOC SEC NO. Flores, Daniel | oF 1935 l Texas | S. PRESENT STATUS (Single, widowed, divorced, or annulled) specify: Maxrrileéd ,o 30 6. STATE DATE. PLACE. AND REASON FOR ALL DIVORCES OR ANNULMENTS wwA" SECTION Ht. SPOUSE 1. NAME OF SPOUSE last-first-middle-maiden) - DATE DF BIRTH 3. PLACE OF BIRTH (spouse ) ie Flores, 06 0 1935 Portland, Oregon 4- DATE AND PLACE OF MARRIAGE 5. CLTIZENSH IF OF SPOUSE (If naturalized, indicate date & place 18 November 1960 OF meter aE aE Tone er Sete Oe) te) USA S. STATE DATE. PLACE. AND REASON FOR ALL SEPARATIONS, DIVORCES OR ANNULMENTS ; tT tHAT J. OCCUPATION 8. PRESENT EMPLOYER ~ Legal Secretary ob 3. EMPLOYER'S OR BUSINESS ADDRESS (No., Street, City, State & Zip Code - Country af not U.S.) Pay Street NW, Washington, D.C. SECTION Of1. RESIDENCE (Since date of last PHS, if overseas residence indicate only city and country) ADDRESS - LAST RESIDENCE FIRST Cnumber, street, city, state,country) Joel, INCLUSIVE DATES (month & vear ) . FROM. TO Jo May 1969 |May 1971 lo : Sept. 197] Feb. 197 OF» ienna a | Feb. 1974 SECTION IV. CHELDREN AND OTHER DEPENDENTS (provide information for all children and dependents } NAME RELATIONSHIP] DATE & PLACE OF BIRTH | CITIZENSHIP Pe) ADDRESS of __|Flores aughter| 3 March 1971 USA _ = : i zenna a o6 Flores aughter|15 March 1974 USA . " 3 e le FORM OBSOLETE PREVIOUS (4) 12+ 70 Witte EDPTIONS “ad .
eae cS EE . REL, WY YES BY BLOOD, MARRIAGE OR ADOPTION WHO EITHER (1) LIVE A SECTION Ve ° . 2) ARE NOT U.S. CITIZENS OR 3) WORK FOR A FOREIGN ‘even er. -Middie ) . 2. LAT LONSHIP 3. DATE_OF BIRTH | 4. val tH (City, ~State, Country) |Richaed,, Nephew ‘OK “New % rte eans , La CITIZENSHIP (Country) ADDRESS OR COUNTRY IN WHICH RELATIVE RESIDES USA Ansbach, Germany EMPLOYED BY Bere QF CONTACT “Army So : Ffodze Fe fF warn" Last: Firat- Middle) : 3. BA E OF BIRTH 4. PLACE OF BIRTH CITIZENSHIP (Country) ADDRESS OR COUNTRY IN WHICH RELATIVE RESIDES EMPLOYED BY FREQUENCY OF CONTACT DATE OF LAST CONTACT NAME (Last-First-Middie) RELATIONSHIP  |3.DATE OF BIRTH] 4-PLACE OF BIRTH (City, State, Coumtry) a ty, State, Country) (3) 5. CITIZENSHIP (Country) - ADDRESS OR COUNTRY IN WHICH RELATIVE RESIDES 7. EMPLOYED BY 8. FREQUENCY OF CONTACT 9. DATE OF LAST CONTACT SECTION VI. PERSONAL DECLARATIONS 1. HAVE YOU BEEN ARRESTED, INDICTED, OR CONVICTED FOR ANY VIOLATION OF Law (Other than for YES (explain X - minor traffic,yiolatjon) SINCE, THE: .DATE OF YOUR RAST PHS below) 2. SINCE THE DATE OF YOUR LAST PHS, HAVE THERE BEEN ANY UNFAVORABLE INCIDENTS IN YOUR LIFE YES (explain WHICH MIGHT REQUIRE EXPLANATION. below) 3. NAME OF YOUR PRESENT IMMEDIATE SUPERVISOR (include Room Number and Extension) MY. Nestor ee 5 4 Tal 03.0) SECTION Vil. , . PERSONS TO BE NOTIFIED IN CASE OF EMERGENCY OT 1. NAME (Last-Fi a Ona as previous PHS 2. RELATIONSHIP 3. HOME ADDRESS (Number, Street, City, State, ZIP code) , ok - HOME TELEPHONE NUMBER oe _ aoe Mi 5S. BUSINESS ADDRESS (Number, Street, City, State, ZIP Code)-iNDICATE NAME OF FIRM| 6. BUSINESS TELEPHONE NUMBER & EXT. OR EMPLOYER. IF APPLICABLE a an : [aw 9. IN CASE OF EMERGENCY, OTHER CLOSE RELATIVES (spouse, mother, father ...}) MAY ALSO BE NOTIFIED. IF SUCH NOTIFICATION 1S NOT DESIRABLE BECAUSE OF HEALTH OR OTHER REASONS, PLEASE LDENTIFY THE PERSONS NOT TO BE NOTIFIED AND THE REASON. SECTION VIII. > ADDITIONAL REMARKS . SIGNATURE OF EMPLOYEE
1. WAME (Pirat-middie- last ) - | Daniel (nun) ‘Flores 3. -4F- MARRIED:  ~ OO: a vember NUMBER AND STREET NUMBER AND STREET “HAVE YOU BEEN ARRESTED; INDICTED. SOR ~ CONVICTED: FOR -ANY“VIOLATION OF LAW (Other than for YE (Exptain minor ‘traffic violation}. SSUNCE ‘THE DATE OF YOUR LAST. ‘PHS . below) SINCE THE ‘DATE OF YOUR LAST.PHS, HAVE THERE BEEN ANY. UNFAVORABLE. ANC IDENTS | iN YOUR LIFE WES (Explai @HICH MIGHT REQUIRE EXPLANATION . . . . . below) ATTY Se oney ADDITIONAL REMARKS (Use reverse if necessary) DATE 2G Dish 1967 cet duwe aim .
14-00000 1. NAME (Firet-middle- last) Daniel (nm) Flores 3..4F MARRIED : : : “ep TalddTe(waiden)- fast) bate OF -MARREAGE © August a DATE TO DATE RUMBER AND STREET DATE TO DATE -. ae NUMBER AND STREET HAVE YOU BEEN ARRESTED, INDICTED, OR CONVICTED FOR ANY VIOLATION OF LAW (Other 3 tha ‘for « minor traffic violation) SINCE THE DATE OF YOUR LAST PHS mt : SINCE THE DATE OF YOUR LAST PHS, HAVE THERE BEEN -ANY UNFAVORABLE WHICH MIGHT REQUIRE EXPLANATION 7 PNET ba Se oS NAME OF YOUR PRESENT IMMEDIATE SUPERVISOR T, Mahoney ADDITIONAL REMARKS (USe reverse if neceasary) Form! 4- ps ute : . (4) 3 . t