404-10129-10002 a ; . } Boos, ' .* “” eo. ft og naan Tee? id ~ DO NOT USE THIS SPACE a “a THIS DATE (Fill In) ISSUED BY * ok PERSONAL HISTORY STATEMENT AXGUST 31, /76/ INSTRUCTIONS ° 1. Answer all questions completely or check appropriate box. If question is not applicable, write “NA”. Write “Un- known” 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 1 GENERAL PERSONAL AND PHYSICAL DATA ‘| 1) FULL NAME (Last-First-Middte) .o . 2. AGE 3. SEX ODRIGUEZ EMIiLioa Americe / 33 VeaRrs WT: IMALE FEMALE 4. HEIGHT 5. WEIGHT 6. COLOR OF EYES 7. COLOR OF HAIR’ 8. TYPE COMPLEXION $. TYPE BUILD Ser fom) / . ROWN | LACK AUDD MEDIUM 10. SCARS (Type and Location) . NONE 11. OTHER DISTINGUSHING PHYSICAL FEATURES NONE 12. CURRENT ADDRESS (No., Street, City, Zone, State and Country) 13. PERMANENT ADDRESS (No., Street, City, Zone, State and oe ra _ Country) AND PHONE NO. ; . F361 S.W.°/179 ST. ‘9327 8. 0 Pome: —_ | | Me EST (Chan S-8341 _FERRINE S7, FLA. (PERQINE S7,FLAL | ; 14. CURRENT PHONE NO. 1S. OF FICE PHONE NO. & EXT. 16. LEGAL RESIDENCE (State, Territory or Country) CEden 5-834! | NA. FLORIDA, U.S. 4A. 7. NICKNAMES NONE 13. INDICATE CIRCUMSTANCES (Including Length of Time) UNDER WHI Fé APRIL (960 Td PRESENT (" HAVAWA,CHBR AND MBM, FLA. as UDERCOVER NAME 20. 1F LEGAL CHANGE, GIVE PARTICULARS (Where and by What Authority}. SECTION Ii POSITION DATA 1. INDICATE THE TYPE OF WORK OR POSITION FOR WHICH YOU ARE APPLYING 2. INDICATE THE LOWEST ANNUAL ENTRANCE SALARY YOU WILL ACCEPT (You will not be considered for any poaition with a lower entrance ealary), $ Ff 608. cé : 4 INDICATE YOUR WILLINGNESS TO TRAVEL OCCASIONALLY FREQUENTLY CONSTANTLY OTHER: 5. INDICATE YOUR WILLINGNESS TO ACCEPT ASSIGNMENT IN THE FOLLOWING LOCATIONS (Check (X) each item applicable) WASHINGTON, D.c. ANYWHERE IN U.S./X [CERTAIN LOCATIONS ONLY (Specify): , SUTSIDE CONTINENTAL U.S. &. INDICATE WHAT RESERVATIONS YOU WOULD PLACE ON ASSIGNMENTS OUTSIDE THE WASHINGTON, D.C. AREA. ADEQUATE PAY AND LIVING CONDITIONS FOR SELF AND FAMILY FORM 444 use Previous EpITION. “1 (4) eeepc RPC eng
a a . . SECTION If |: ” CITIZENSHIP 1. DATE’ OF BIRTH 2. PLACE OF BIRTH (City, State, Country) 3. PRESENT CITIZENSHIP (Country) Saw. 27,1928| HAVANA, CUBA U.S.A. - : 4. CITIZENSHIP ACQUIRED BY [S. DATE NATURAL- 6. NATURALIZATION CERTIFICATE NO. 7, COURT ISSUING NATURALIZATION CERTIFICATE B. ISSUED AT (City, State, Country) 5. Direer Couat ef EXsrenn Wisp. of Lousstaue ew Gre EAN S LA. 9. HAVE YOU HELD PREVIOUS NATIONALITY 10. iF YES, GIVE NAME OF COUNTRY Xives | [xo Cu GBA 11, GIVE PARTICULARS CONCERNING PREVIOUS NATIONALITY. CUBAN BY BIR TH : ARS 12, HAVE YOU TAKEN STEPS TO CHANGE 13. GIVE PARTICUL PRESENT CITIZENSHIP x A NO A. . 14. IF YOU HAVE APPLIED FOR U.S. CITIZENSHIP, WHAT IS PRESENT STATUS OF YOUR APPLICATION (Firat Papers, Etc.)? 16. PORT OF ENTRY 17. ON PASSPORT OF WHAT COUNTRY UNE S , (¥€ MIAMI, FLA. SWISS PROTECTIVE Passport 18. LAST U.S. VISA (No., Type, Place of Jaaue) 19. DATE VISA ISSUED RESIDENT | 5. EMBASSY IN HAVANA, CUBR Nov. S/F¢Z SECTION IV EDUCATION bd 1. 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 | YRADE, BUSINESS, OR COMMERCIAL SCHOOL GRADUATE GRADUATE STUDY LEADING TO HIGHER DEGREE | TWO YEARS COLLEGE OR LESS . 4 MASTER'S DEGREE || DOCTOR'S DEGREE ; 2. ELEMENTARY SCHOOL 1. NAME OF ELEMENTARY SCHOOL 2. ADDRESS (City, State, Country) COLEGIo DE LA SALLE) WAavanwa , CUBA Sep. /93¢ 18 Nov. (742 _ Xie Ce . | 1. NAME OF HIGH SCHOOL CE AO T n f é New Oeleans , &k Noy. (F442 _T4 Tune. (€¥S be ed 3. DATES ATTENDED (From-and-To) 4. GRADUATE : Pp ofves 4, COLLEGE OR UNIVERSITY STUDY ; SUBJECT DATES ATTENDED DEGREE DATE SEM/OQTR NAME AND LOCATION OF COLLEGE OR UNIVERSITY ® REC'D HOURS [Masor| Minor | From | to | (Specity) if ; iN — _ ae - . . e o . if a . me ‘ eel fo 4 v ¥ A : y, "V4  LoursiqwalSeush| faewch| Hoa \/ (>. . SECTIONUV CONTINUED TO PAGE 3 nd 2 ‘ i8 & FE ]2 = a tn] 9 4 =
5. {F A GRADUATE DEGR ‘FA OF THE THESIS AND EE HAS BEEN NOTED IN ITEM 4 WHICH REQUIRE SUBMISSION OF A WRIT RIEFLY DESCRIBE ITS CONTENT. a ® TEN THESIS, INDICATE THE TITLE se £4 EPITETO EW LAS CBRAS DE BERCES (De wor REmMEN BER fer rrreé). A DETAILED:  STUDy OF THE ANY USES OF THs EPrruHer in BERCEC'S WORKS At2TH Cevrury WRITER: NEL DING A CROSS - REFER eNCE SISTING OF Aka EPITHETS AS SHowNn Ih His WRITINGS we 6. TRADE, COMMERCIAL AND SPECIALIZED SCHOOLS ’ ““ “SECTION IV CONTINUED FROM PAGE 2 ee = es 77 7. MILITARY TRAINING (FULL TIME DUTY IN SPECIALIZED SCHOOLS SUCH AS ORDNANCE, INTELLIGENCE, COMMUNICATIONS, ETC.) [NAME AND ADDRESS oF sewoot  [_sTUDVORsPeciaLizaTion [From [70 Won es 77, 8. OTHER EDUCATIONAL TRAINING NOT INDICATED ABOVE. “1. LANGUAGE (List below each language in which you possess any degree of competence. Indicate your proficiency to Read, Write or Speak by placing a check (X) in the appropriate box(es). CORTUGL LEVEL @ | SECTION V FOREIGN LANGUAGE ABILITIES COMPETENCE - IN ORDER LISTED Shenk DOME LPP Se TS || Zroviev | | 1] | TTT | XX 2. IF YOU HAVE CHECKED “ACADEMIC STUDY" UNDER "HOW ACQUIRED", INDICATE LENGTH AND INTENSIVENESS OF STUDY. FROM (94§ to l95SY STUDIED THE RemtpancEe LAN QUAGES AT THE GRADUATE N.A. R-Read, W-Write, $-Speak HOW ACQUIRED EQUIV- ALENT “LIMITED ADEQUATE | ADEQUATE) FOR To BVIOUSL ° FOR KNOW- NATIVE NATIVE OP sanien* RESEARCH] TRAVEL LEDGE OF FLUENCY COUNTRY LX X LTPP PB HEHE TH Rt +} eS | 3. IF YOU HAVE INDICATED FLUENCY FOR A LANGUAGE HAVING SIGNIFICANT DIFFERENCES IN SPOKEN AND WRITTEN FORM, EX- PLAIN YOUR COMPETENCE THEREIN. NR. 4. DESCRIBE YOUR ABILITY TO DO SPECIALIZED LANGUAGE WORK INVOLVING VOCABULARIES AND TERMINOLOGY IN THE SCIEN- TIFIC, ENGINEERING, TELECOMMUNICATIONS, MILITARY, AND OTHER SPECIALIZED FIELOS. FAMILIAR WITe, SC/ENTIEIC BNO ENGIN EERING TERMINOLOGY iN SPANIS Ef. “— 3. IF YOU HAVE NOTED A PROFICIENCY IN LANGUAGE, WOULD YOU BE WILLING TO USE THIS ABILITY IN ANY POSITION FOR WHICH YOU MIGHT BE SELECTED? DE Yes (] xo -3-
~@- SECTION Vi - GEOGRAPHIC AREA KNOWLEDGE AND FOREIGN TRAVEL —s List BELOW ANY FOREIGN REGIONS OR COUNTRIES IN WHICH YOU HAVE TRAVELLED OR GAINED KNOWLEDGE AS A RESULT OF * RESIDENCE, STUDY OR WORK ASSIGNMENT. INDICATE TYPE OF KNOWLEOGE SUCH AS TERRAIN, HARBORS, UTILITIES, RAIL- ROADS, INDUSTRIES, POLITICAL PARTIES, ETC. KNOWLEDGE ACQUIRED BY reavesferuoe| sage TRAVELISTUDY | ASSIGN: MENT Comenqi¢ ¢ SOCi At eeTuk PM PLERCE ~ (fie Pe. aright: (FS “S96 Mw. dj. ao “~~ DATES OF ’ RESIDENCE OR TRAVEL DATES AND PLACE OF STUDY s NELOGS FE 1) Expiaedi- Seph 2 (FEO (nor Renewed) . SECTION Vii TYPING AND STENOGRAPHIC SKILLS va) NA. | [erecc | [seecowritine | |stenotvree | | oTHER (Specify): 2. INDICATE OTHER BUSINESS MACHINES WITH WHICH YOU HAVE HAD OPERATING EXPERIENCE ORT RAIHLG. (Comptometer, Mimeograph, Card Punch, Etc.). é = MIMEOGRAPH , ADDING MACHINE, CALCUL ATOR , DICTATING MACHINE . SECTION VIII SPECIAL QUALIFICATIONS fe List aut HOBBIES AND SPORTS IN WHICH YOU ARE ACTIVE OR HAVE ACTIVELY PARTICIPATED. INDICATE YOUR PROFICIENCY N EAC FISHING ve / : i ‘NG, HUNTING SWIMMING CQood UNDERWATER RESISTANCE ) PiloToGRA PHY (BtAck # wHiTE AwD Cocoe) | MUS to pP , ‘ Bow hy oft Chess. Avean C (@ ALL OF THe AgovEe .- G Lay SEVEROL WWSTRUMENTS GY EAR), FLYING A 2. INDICATE ANY SPECIAL QUALIFICATIONS RESULTING FROM EXPERIENCE OR TRAINING WHICH MIGHT FIT YOU FOR A PARTICULAR POSITION OR TYPE OF WORK, . Tegcwive heb BIMimsTRgTIVE FR PERIENCE SECURED AT THE UniveRS: Ty LEVEL AWD IN FOREIGN TRADE UANAGEMENT ®ESPECTIVELY. Akso CRPACITY To CARRy our WDE PENDENT PESERRCH AT THE GRapuRTe LEVEL. 3. EXCLUDING BUSINESS EQUIPMENT OR MACHINES WHICH YOU MAY HAVE LISTED IN ITEM 2, SECTION VIl, LIST ANY SPECIAL SKILLS YOU POSSESS RELATING TO OTHER EQUIPMENT AND MACHINES SUCH AS OPERATION Of SHORTWAVE RADIO (indi- cate CW apeed, sending and receiving), OF FSET PRESS, TURRET LATHE, SCIENTIFIC AND PROFESSIONAL DEVICES. FAMILIAR “WITH GENERAL SCEVTig¥e APPARATUS AS MAY BE PRESENT IW A MEnch. ResERCCH “A Ge RATORY . Beckman S} echoph foe Tay (Div owe VEOR RESEARCH AT TULANE MEDCAL e400) SECTION VIN CONTINUED TO PAGE 5 , : ( (
. + ~ . . » ~ SECTION VUI CONTINUED FROM PAGE 4 - ARE YOU NOW OR HAVE YOU EVER BEEN A LICENSED OR CERTIFIED MEMBER OF ANY TRADE OR PROFESSION, SUCH AS PILOT, ELECTRICIAN, RADIO OPERATOR, TEACHER, LAWYER, CPA, MEDICAL TECHNICIAN, ETC.? Deves co . NG : 5. IF YOU HAVE ANSWERED “YES? TO ABOVE, INDICATE KIND OF LICENSE AND STATE_ISSUING LICENSE (Provide License Registry Number, if known). : Studey t Bly fe Coa Fi fen te WES ~ AGF 3957 \ 6. FIRST LICENSE OR CERTIFICATE (Year of Iseue) 7. LATEST LICENSE OR CERTIFICATE (Year of Isaue) A-18-S¢ M4 8. LIST ANY SIGNIFICANT PUBLISHED MATERIALS OF WHICH YOU ARE THE AUTHOR (Do NOT submit copies unless requested). INDICATE THE TITLE, PUBLICATION DATE, AND TYPE OF WRITING (Non-Fiction or Scientific articfea, General Intereat aubjecta, Novela, Short . Stories, Ete.). . WA. bs 4 9. INDICATE ANY DEVICES WHICH YOU HAVE INVENTED AND STATE WHETHER OR NOT THEY ARE PATENTED. N.A. 10. LIST PUBLIC SPEAKING AND PUBLIC RELATIONS EXPERIENCE. IN COLLEGE AWD AS A TunyiwR EXECuT WE (W FOREIGN TRADE 11. LIST ANY PROFESSIONAL, ACADEMIC OR HONORARY ASSOCIATIONS OR SOCIETIES IN WHICH YOU ARE NOW OR WERE FORMERLY A MEMBER. LIST ACADEMIC HONORS YOU HAVE RECEIVED. Phi i Lolk 1 Nakowa? Uowen Society of Rowan ne a a ia Aisearcan Aasocialein of Teaches of rie h cud Pog kiguese . Graduate Sch Bas Mis offered 4 Lhe Skt o f how é sane, tad’ Filane Unwe0s: oe (unde winey XZ DID Five YEgas of GRAD—RTE unger) 7 Howokney MEV Tions AND MEDALS. | NOTE: (LIST LAST POSITION FIRST.) Indicate chronological history of employment for past 1§ years. Account for all periods including casual employment and all periods of unemployment. Giveaddress and state what you did during periods of unemployment. Liat all civilian employment by a foreign Government, regardless of dates. In completing item 9, *De- acription of Duties* consider your experience carefully and provide meaningful, objective statements. 2. NAME OF EMPLOYING FIRM OR AGENCY (CENTURY ELECTRIe ComMPANY! 4. KIND OF BUSINESS ‘ 2 4 MAWAFRETUBER OF MOTORS. GEVERA TOES » ETC. . |, Exfoal Mashed A NsjFowt Disraicr  MAMAEE | $ 4goo [Pen Aba TH laps %. DESCRIP TION OF DUTIES Te PdoMtoere AND Stuer The SALE S* Cévrdle MoTORS, GE ERETORS, 4YD RELATED EG Phen ip THE TERK TORY PE CUBA, Habe To OPRRRTE (i COLLECT og WHEN NECESSARY, T= SIANAGCE THE HAVANA WsTheT Sie i OEE ON Suck PESAeNSA BUITY IV WE ABSENCE of THE Darecr~ MGe. 19 <0K ASTER THE wy THREST oF Covruky El&e. Co) W CXBh 10. REASONS FOR LEAVING PRESEN T Condi TioWws (4 CHBR SECTION IX CONTINUED TO PAGE 6
14-00000 3. ADDRESS (No.,, Stree 2 City, State, a ST Way 4. KIND OF BUSINESS 5. NAME OF SUPERVISOR COLLEGE Dr. Johku E. Eughliek ; Chaumay F 6. TITLE OF JoB 7. SALARY OR EARNINGS [8 CLASS. GRADE (If Federal Service) Graduate Asst [S$ gee [PER Apo td [ays 9. DESCRIPTION OF DUTIES TEACHER OF BEGINNER A> INTERME DIATED SPAMISH WW Tye Celie@é LEVEL. 1 ASSIST wir Regis TRATION BD DEORRTAMENTAL FunerieNS, $0. REASONS FOR LEAVING Je ACCEPT ABOVE Posi Tian 2. NAME OF EMPLOYING FIRM OR AGENCY 1. INCLUSIVE DATES (From and To - By Mo. and ¥r.) : A BERLITZ) Sctloow OF LANGUAGE Az. SuUWVWE S/F Ld 3. ADORESS(No., Street, City, State, Country) (ZV TERVATIOVAL TRADE MART New CRLEBAVS , LA, 4-S- & KIND OF BUSINESS 3. NAME OF SUPERVISOR LAVNGURGE SCHoeOok& Mra. HALL Diaecter 6. TITLE OF JOB 8. CLASS. GRADE (If Federal Service) Tor esson | 10. REASONS FOR LEAVING Te ACCEPT SBEVE PeSITION AND PARSUET AV ADVANCED DEGREE 2. NAME OF EMPLOYING FIRM OR AGENCY TULANE UNIVERSITY MEDICAL SCHOOL | Ty 1. INCLUSIVE DATES (From and To - By Mo. and Yr.) 3. ADDRESS (No., Street, City, State, Country) £: ff. i ~~ wa“ AWE AVE-. (A £. OAL S LA: 5 4. KIND OF BUSINESS 5. NAME OF SUPERVISOR . f 7 ee MEDICAL St6vor De. Wee 6. TITLE OF JoB 8. CLASS. GRADE (If Federal Service) Medicat [festweeh “Vechuithay L$ 200-00 [PER pert | 3. DESCRIPTION OF DUTIES \ e W CHARGE 8F SPECTR Pile TOME T RIC ANAL YSIS THE CARDIO - VRSECuLAR RESERRCH <ABe LET 2 ay. 10, REASONS FOR LEAVING CON CLUSsON OF RES EAR CL ! 1. INCLUSIVE DATES (From and To - By Mo. and Yr.) 2. NAME OF EMPLOYING FIRM OR AGENCY 3. ADDRESS (No., Street, City, State, Country) 4. KIND OF BUSINESS 5. NAME OF SUPERVISOR - 6 TITLE OF JOB Le 7. SALARY OR EARNINGS &. CLASS. GRADE (If Federal Service) = , $ [Per | | e r SECTION IX CONTINUED TO PAGE 7 - ‘Seether een eneanc nae?
14-00000 9. DESCRIPTION OF DUTIES 10. REASONS FOR LEAVING 1. INCLUSIVE DATES (From and To - By Mo. and Yr.) 2. NAME OF EMPLOYING FIRM OR AGENCY . ADORESS (No., Street, City, State, Country) . KIND OF BUSINESS §. NAME OF SUPERVISOR . TITLE OF JOB 7. SALARY OR EARNINGS 8. CLASS. GRADE (If Federal Service} - DESCRIPTION OF DUTIES 10. REASONS FOR LEAVING 1. INCLUSIVE DATES (From and To - By Mo. and ¥r.) 2. NAME OF EMPLOYING FIRM OR AGENCY ADDRESS (No., Street, City, State, Country) . KIND OF BUSINESS 8. NAME OF SUPERVISOR . TITLE OF JOB 7. SALARY OR EARNINGS 8. CLASS. GRADE (if Federal Servive) $ . DESCRIPTION OF DUTIES 10. REASONS FOR LEAVING IF PRIOR SERVICE WITH THE FEDERAL GOVERNMENT IS NOTED ABOVE, INDICATE THE NUMBER OF YEARS CREDITABLE TOWARD U.S. CIVIL SERVICE RETIREMENT, IF KNOWN. HAVE YOU EVER SEEN DISCHARGED OR ASKED TO RESIGN FROM ANY POSITION. CJres Bano HAVE YOU LEFT A POSITION UNDER CIRCUMSTANCES WHICH You DESIRE TO EXPLAIN? (Clres BNO IF YOUR ANSWER TO EITHER OR BOTH QUESTIONS is “YES", GIVE DETAILS
14-00000 SECTION X - ‘- . . MILITARY SERVICE r : 1. CURRENT DRAFT STATUS ‘ 1. ARES YOU REGISTERED FOR THE DRAFT UNDER $s THE UNIVERSAL MILITARY TRAINING AND SERVICE ACT OF 1346 (As,amended) 4. IF DEFERRED, GIVE REASON MABE TES WIELL/ Tus 2. MILITARY SERVICE RECORD 1. CURRENT AND/OR PAST ORGANIZATIONAL MEMBERSHIP MARINE AIR COAST |MERCHANT| NATIONALIAIR NAT°L| FOREIGN ORGAN. OR MiL. ARMY NAVY CORPS | FORCE MARINE | GUARD | GuaRD | SERVICE (Specify): pHaveserveo=[ 0 TUE CUT CO OC” NOW SERVING | a A A 3. DATE SEPARATED FROM EXTENDS ACTIVE puny (Past servic] 4. TOTAL LENGTH O EXTENDED ACTIVE OUTY IN U.S. ARMED FORCES (Past and/current service) i PAST meme | ?. RANK GRADE oR PAST SERY, CURRENT SERVICE SB. SERVICE, SERIAL OR FILE NUMBER (i! now serving, provide cur / tent number) 3. PRIMARY MILITARY OCCUPATIONAL j CURRENT SERVICE SPECIALTY (Moe or Designatod) AND Tt CHECK (X) AS APPROPRIATE LENGTH OF ACTIVE DUTY IN FOREIGN MILITARY OR- 6. TOTAL CURRENT SERVICE GANIZA 5. DATE ENTERED ACTIVE DUTY opm 10. SECONDARY MIL. OCCUPATIONAL a SERVICE CURRENT SERVICE SPECIALTY (Moe or Deasigndtor) AND TITLE lf. BRIEF DESCRIPTION OF MILITARY =< os (indicate whether agplicable to past pr current service) 12. CHECK (X) TYPE OF SEPARATION FROM ACTIVE DUTY | HONORABLE DISCHARGE | | RETIREMENT FOR SHRVIC | UNDUE HARDSHIPS RELEASE TO INACTIVE DUTY | | RETIREMENT FOR dawakt cisaiuiyy | OTHER: | RETIREMENT FOR AGE | | RETIREMENT FOR/PHYfICAL ot JABILITY «| 13. CHECK (x) LOMPONENT IN WH CH YOU SERVED ;RecuLar | | RESERVE (Including the National and Air National Guard) | | OTHER (Including AUS) 3, MILITARY RESERVE, NATIONAL GUARD AND ROTC STATUS 1. DO YOU NOW HAVE! RESERVE STATUST 3. ARE YOU NOW A MEMBER © 2. ARE YOU NOW A MEMBER OF THE THE ROTC? YES NATCL. GRD. OR AIR NAT'L. 4, iF YOU HAVE ANSWERED “YES* TO ITEMS 1,2 OR 3 ABOVE, CHECK COMPONENT MEMBERSHIP BELOW Pat [ae rome jm narrecuane fl [anny roy | [aeronce nord 5. CURRENT RANK, GRADE OR 6. DATE OF APPOI RATE RANK 8. CHECK (X] CURRENT RESERVE CATEGORY 3. PRIMARY MILITARY OCCUPATIONAL SPECIALTY (Mg E j nd@tor) AND TITL AND Le -. 11. BRIEF DESCRIPTION OF MILITARY RESERVE DU 12. ARE YOU CURRENTLY ASSIGNED OR ATTACHED 13. iF you HAVE. ANSWERED “YES° TG ITEM 12, GIVE UNIT OR AGENCY re. A RESERVE, NATL. GUARD OR ROTC TRAINS] AND ADDRE: NG UNIT 14. HAVE YOU A MILITARY MOBILIZATION ASSIGN- er 18. IF You Hay venhee rey TO ITEM t4, GIVE UNIT OR AGENCY MENT? il . x] Ne | : 6. INDICATE TOTAL MILITARY SERVICE| YEARS | MONTHS | 17. WHERE Age YOWR/SERVIEE RECORDS KEPTT FOR LONGEVITY PURPOSES INCLU ING ACTIVE AND INACTIVE DUTY HA. ° 4.. —
5 . . . ee eg, ae ew d FIMANCIAL STATUS “ _ ARE YOU ENTIRELY DEPENDENT ON YOUR SALARY? (bq ves 2. IF YOUR ANSWER IS "NO" TO THE AGOVE, STATE SOURCES OF OTHER INCOME 3. BANKING INSTITUTIONS WITH WHICH YOU HAVE ACCOUNTS NAME OF INSTITUTION . ADORESS (City, State, Country) The Rovat Bavk of CAVADA MAVANA, CUBA. 4, HAVE You EVER BEEN IN, OR PETITIONED FOR, BANKRUPTCY, {_] ves Bel no . 5. IF YOUR ANSWER IS “YES" TO THE ABOVE, GIVE PARTICULARS, INCLUDING COURT AND DATE(S) W. A. 6. GIVE THREE CREDIT REFERENCES IN THE UNITED STATES “ H ot” fi SILT teal GEE L ta 7. OO YOU RECEIVE AN ANNUITY FROM HE UNITED STATES OR DISTRICT OF COLUMBIA GOVERNMENT UNDER ANY RETIREMENT ACT, PENSION, OR COMPENSATION FOR MILITARY OR NAVAL SERVICE? ] ves NO 8. IF YOUR ANSWER iS “YES” TO THE ABOVE QUESTION, GIVE COMPLETE DETAILS NA. 9. DO YOU HAVE ANY FINANCIAL INTEREST IN, OR OFFICIAL CONNECTIONS WITH NON-U.S.- CORPORATIONS OR BUSINESSES; OR IN OR WITH U.S. CORPORATIONS OR BUSINESSES HAVING SUBSTANTIAL FOREIGN INTERESTS? {_] ves Bef no (If anawer “VES*, furniah detaite on separate eheet.) SECTION XH MARITAL STATUS . ; ; 1. PRESENT STATUS (Single, Married, Widowed, Seperated, Divorced, or Annulled) SPECIFY: M A fe ED 2. STATE DATE, PLACE, AND REASON FOR ALL SEPARATIONS, DIVORCES OR ANNULMENTS N: ft. \ WIFE, 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. . (Firat) (Middle) (Maiden) : . (Laat) “PRULINE | . JuUuANITA | ROSS | . RoDRigGuée z’ 4. STATE ANY OTHER NAMES EVER USED INDICATE CIRCUMSTANCES (Including length of time) UNDER WHICH ANY ; OF THESE NAMES WERE USED. {f LEGAL CHANGE GIVE PARTICULARS ‘ : (Where and by what authority). USE EXTRA SPACE PROVIDED ON PAGE 16 Vhalh, CNICKWAME SINCE Ch1e Hood) 6 PLACE OF MARRIAGE (City, 3. NAME OF THIS FORM TO RECORD THIS INFORMATION. §. DATE OF MARRIAGE State, Country) (JUNE (6, 1¥¥$ — ~C, - S$. A 10. CAUSE OF DEATH @, OATE OF DEATH fi. CURRENT ADDRESS (Give last address, if daceased) F36/ Sis (IF SE PERRINE S7~ FLA. “S.A. 18. PLACE OF BIRTH (City, State, Country} 2. DATE OF BIRTH 14. CITIZENSHIP SAN. 2 / i, _82GALuS A) 9. W-S-4. “U.S.A. -G-
? -10- ‘ ~ SECTION XU CONTINUED FROM PAGE 9 a. iF BORN OUTSIDE U.S. SATE OF ENTRY 1S. PLACE OF ENTRY HA- WA. ; ; 8. CITi 18. Cie, ; 16. FORMER CLPIZENSHIP(S)  ZCouners(ies)7 Re Reobinia © WA WHERE OAL ity, State, Country) WA. 20. PRESENT EMPLOYER (Also give former employer, or if spouse deceased ar unemployed give last two employers) NA. 18. OCCUPATION HOUSE WIPE 2t. EMPLOYER’S OR BUSINESS ADDRES (No., Street, City, State, Country) 22. DATES OF MILITARY SERVICE (From and to - By Mo. and ¥r.) 23. BRANCH OF SERVICE 24, COUNTRY WITH WHICH MILITARY SERVICE AFFILIATED VA - WA. 25. DETAILS OF OTHER GOVERNMENT SERVICE, U.S. OR FOREIGN wv. A. SECTION SCL SWINE FOTO DREN AND OTHER DEPENDENTS Xi CHILDREN AND OTHER DEPEN DENTS 1. PROVIDE THE FOLLOWING INFORMATION FOR ALL CHILDREN AND DEPENGENTS an ‘GIE SW-17E ST &, ia VERRINE $7, Fbdby/ F365 Sie. SIPS ms. a3 f (i PE ARIME & LA: SS Si 19 $7: 3. NUMBER OF OTHER DEPENDENTS (Including spouse, Parents, etep-parents, aiater, etc.) WHO DEPEND ON YOU FOR AT LEAST 50% oF THEIR SUPPORT, OR CHILDREN OVER 21 YRS. OF AGE WHO ARE NOT 2. NUM chdd ILDREN ing step- teen and adented TEN ene ARE SE UNMARRIED, UNDER 21 YRS. OF AGE, AND NOT SEL F-SUPPORT 3G. }t. FULL NAME (Laat-Firet-Midtin) . eDRIGUEZ, Akwes7z NEPOLEON, 4. CAUSE OF DEATH de INDICATE CIRCUMSTANCES (ineluding length of time) UNDER WHICH HE HAS EVER USED THESE NAMES. IF LEGAL CHANGE, GIVE PARTICULARS (Where and by what authority). USE EXTRA SPACE PROVIDED On PAGE 16 OF THIS FORM TO RECORD THIS INFORMATION, - 6. CURRENT ADDRESS - Give met ediress, if deceased (No., Street, City, State, Country) = rer 7. DATE OF BIRTH A eg Pax ART, | 8 PLACE OF BIRTH (Cid, “wf ! Uy, vas , 1F BORN OUTSIDE U.S. -IATE OF ENTRY Neu. S562 12. FORMER CITIZENSHIP(S) Courtry(iee)7 NA 49. 13. DATE U.S. CITIZENSHIP ACQUIRED 18. OCCUPATION RETIRED 17. EMPLOYER’S BUSINESS GORE OR FATHER’S BUSINESS ADDRESS IF SELF- £26 PYVE ST. 18.DATES OF MILITARY SER¥CE (Penrend-To, Wek. 20, COUNTRY WA. PR Of §, EMBASSY 147 RECENT CAST#o REUNION
14-00000 1. FULL NAME (Leat-F irat-Middle) _ EM fg 2. LIVING ‘CAsawova * INDICATE CIRCUMSTANCES (including len§th of time) DER WHICH SHE HAS EVER USED THESE NAMES. IF LEGAL CHANGE, GIVE PARTICULARS (Where and by what authority), USE EXTRA SPACE PROVIDED ON PAGE 16 OF THIS FORM TO RECORD THIS INFORMATION. DATE OF BIRTH. CITIZENSHIP (D f. 1ifso FORMER CITIZ ENSHIP(S! /Country{iea}7 lV. New DATE U.S. CITIZENSHIP ACQUIRED Vv 4 16. PRESENT EMPLOYER (Give add *S BUSINESS ADDRESS IF SELF EMPLOYED A. {8 BRANCH OF SERVICE WA, 1S. OCCUPATION last employer, if Mother ie deceased or unemployed FfO4S ew, KE EMPLOYER'S BUSINESS ADDRESS OR MOTHER DATES OF MILITARY SERVICE (From-and- 20, COUNTRY 21. DETAILS OF OTHER GOVERNMENT SERVICE, U.S. OR POS eo ° CEVSRSHIP OFFICE DuRING WwoaLd WAR SECTION xvi BROTHERS AND SISTERS (Including Halt-, ft. FULL NAME (Laat-F iret-Middie) 2 RELATIONSHIP (perke GUE, ARNES TO fos Ey Bho THER. 4. CURRENT ADDRESS (No., Street, City, Zane, State, Country) \2/2_ MAPLE Rd. , Metae: La. Us-f. 2. RELATIONSHIP Country) 2. RELATIONSHIP 3. CITIZENSHIP (Country) % LIVING |_fves | [xo %- RELATIONSHIP ‘ 3. CITIZENSHIP (Country) * 5. LIVING , |_jves | [xo | 2 RELATIONSHIP 3. CITIZENSHIP (Country) 8. Living | biving |_[ves [ [xo] 2. RELATIONSHIP 3. CITIZENSHIP (Coun try) Spel pe | 2 RELATIONSHIP 3. CITIZENSHIP (Country) & Living Country) Country) Country) -Tl-
5 @ -12- SECTION XVEl . FATHER-IN-LAW s Di. PULL NAME (Laet-Firat-Middie) kad 2. LIVING I 3. DATE OF DEATH 4. CAUSE oF DEATH LSet Meee SAwroapy | [Te pgm] Tine so eer vee 4 INDICATE CIRCUMSTANCES (including length of time) UNDER WHICH HE Has EVER USED THESE NAMES. IF LEGAL CHANGE, GIVE PARTICULARS (Where end by what authority). USE EXTRA SPACE PROVIDED ON PAGE 16 OF THIS FORM TO RECORD THIS INFORMATION. 3. STATE OTHER NAMES HE HAS USED SAM (wee nanpe SCE Chic D100?) * CURRENT OR LAST ADDRESS (No. Street, City, State, Country) i y om 5 Mey Houte 2, Box sw EDENTON, Wc, DATE OF BIRTH | 8& PLACE OF BIRTH (City, State, Country) we 10 BILE), ALy BAALTA, US. 1F BORN OUTSIDE U.S.- DATE OF ENTRY if. PLACE OF ENTRY FORMER CITIZENSHIP(S} LCountry(ies)) 14. WHERE ACQUIRED (City, State, Country) WA. OLS. 8. CITIZENSHIP Of. S-#. 13. DATE u.s. CITIZENSHIP ACQUIRED 1S. OCCUPATION 16. PRESENT EMPLOYER ‘RP BAER if Father-in-Law is deceased or unemployed) CDVEN Ton) (Give last employer, AxD Co, {. FULL fTlAME (Last-Firat-Middie) 8. DATE OF DEATH 4. CAUSE OF DEATH ! XDe [px ae MA BOV TA Py 5S. STATE OTHER NAMES SHE INDICATE CIRCUMSTANCES (including length of time) UNDER WHICH SHE HAS EVER USED THESE NAMES. IF LEGAL CHANGE, GIVE PARTICULARS (Where and by what authority). USE EXTRA SPACE PROVIDED ON PAGE 16 OF THIS FORM TO RECORD THIS INFORMATION, CURRENT OR LAST ADDRESS (No., Street, City, State, Country) . Bex Svo_ EDEN TOV) NC. “es”. 8. PLACE OF BIRTH (City, State, Country) Miss. PLACE OF ENT 6. 7. DATE OF BIRTH Dec. RHF FF" 10. fF BORN OUTSIDE u.s. MAA - FORMER CITIZENSHIP(S) LCountry(iea JP RY MA. DATE w.s. CITIZENSHIP i4. WHERE ACQUIRED (City, State, Country) ACQUIRED NA. NA . {6 PRESENT EMPLOY ER (Give laat employer, if Mother-in-Law is deceased og unemployed) MM, A. 12, Ls FULL NAME {Last-First-Middle) LOPEZ ELENA: 4. ADDRESS OR CO NTRY IN WHICH RELATIVE RESIDES (2/12 Marre R 44. US. fA. 6. CITIZENSHIP (Country) 7. FREQUENCY OF CONTACT MEXICAN ONCE 1. FULL NAME (Laet-F iret-Middie) 8. DATE OF LAST CONTACT SUNG S964 ADDRESS OR COUNTRY IN WHICH RELATIVE RESIDES 3. FREQUENCY OF CONTACT CITIZENSHIP (Country) . » FULL NAME (Last-Firet-aiddte) - ADDRESS OR COUNTRY IN WHICH RELATIVE RESIDES CITIZENSHIP (Country) 3. FREQUENCY OF CONTACT RELATIONSHIP EMPLOYED By - 6. DATE OF LAST CONTACT
f SECTION XIX CONTINUED FROM PAGE 12 6. SPECIAL REMARKS, IF ANY, CONCERNING RELATIVES NOTED IN SECTION XIX ABOVE Above aetlalive Gas beeg & covlswuous siden fF hy b> 4“ S.A, Sade VF ES~ by New Op lens, Ln. RELATIVES BY BLOOD, MARRIAGE OR ADOPTION WHO ARE IN THE MILITARY OR CIVIL SECTION XX SERVICE OF THE UNITED STATES i. NAME (Last-Firet-Middie) 2. RELATIONSHIP 3. AGE a, CITIZENSHIP fess. Jose Pd Au peer nionlee w aw | vo | usa | 3. ADDRESS (No., Street, City, State, Country) & TYPE AND LOCATION OF SERVICE (If imown} P MARINE Plier aD A pGTe GRAPHER ‘Ws TRUET OR. Houke 2 Box SISH , Feusnesl, PENSACOLA 7OnV i a eee $. ADDRESS (No., Street, City, State, Country) SECTION XXi REFERENCES, ACQUAINTANCES, AND NEIGHBORS 1. LIST FIVE CHARACTER REFERENCES, NOT RELATIVES, IN THE U.S., WHO KNOW YOU INTIMATELY NAME 9 BUSINESS ADDRESS RESIDENCE ADDRESS (Last-Fireat-Middie) , Street, City and State) (No., Street, City and State) W0/as MARRK Ham ST: , wre Zi éeNe: - fs EREE WOOD _ EBASeo SERUICES NYy- “Po. Box 2a DINE PLU, AR 2. LIST FIVE PERSONS, IN THE U.S. WHO KNOW YOU eS NOT RELATIVES, SUPERVISORS OR EMPLOYERS NAME BUSINESS ADDRESS RESIDENCE ADDRESS { Last-Firet-Middie) (No., Street, City and State) (No., Street, City and State) [S- Gaewes—_ i aie S. WwW. BAR i A er ©, g/ . hd. T- Wece UWk. Sw Ag COWIE SERVICE 23/0 CAST ‘G WETS : Ness Be Les n.$) Lfere $ & asi PE OE & 2, 6 3. LIST THAEE NEIGHBORS AT YOUR MOST RECENT NORMAL RESIDENCE IN THE U. 3. NAME BUSINESS ADDRESS RESIDENCE ADDRESS (Laat-F isat-Middie) (No., Street, City and State) (No., Street, City and State) 7 ae MEMCAL Shoo 6. -13-
: @ ‘ ® -14- ‘SECTION XXil CLUBS, SOCIETIES, AND OTHER ORGANIZATIONS NOTE: 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 ér have belonged. ADDRESS DATES OF MEMBERSHIP NAME AND CHAPTER (Number, Sireat, City, State, Country) “THLawe Univers Ty /¥S1 hd ae fC - hemor Fo. DE PRiw jum VERS ITy rs x SECTION XXili RESIDENCES FOR THE PAST 15 YEARS ADDRESS - LAST RESIDENCE FIRST (Number, Street, City, State, Country) ¢ £ ct Ss & ~, To Och. (FS6 3 ' Wisy- Oct. het ' ! £ em, * “Sy o~ . &§ Q sh a * SESS wha CFS 4 Q Py i" tenn H , Cob LF¢ + ry ¢
* SECTION XXIV ; ADDITIONAL INFORMATION i 1. DO YOU ADVOCATE OR HAVE YOU EVER ADVOCATED; OR ARE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF; OR HAVE YOU EVER SUPPORTED OR GEEN ASSOCIATED WITH ANY POLITICAL PARTY. INDIVIDUAL OR ORGAN - IZATION WHICH ADVOCATES OR TEACHES THE OVERTHROW OF THE GOVERNMENT OF THE UNITED STATES BY FORCE, VIOLENCE OR OTHER UNCONSTITUTIONAL MEANS, OR SEEKS BY FORCE OR VIOLENCE TO DENY PERSONS THEIR RIGHTS UNDER THE CONSTITUTION OF THE UNITED STATES? 2. 1F YOU HAVE ANSWERED “YES® TO THE ABOVE QUESTION, EXPLAIN NA. L | YES 4. IF SO, TO WHAT EXTENT? 3. DO YOU USE OR HAVE YOU EV - ER USED INTOXICANTS ES AA 5. DO YOU USE OR HAVE YOu | | YES 6. IF SO, TO WHAT EXTENT? EVER USED NARCOTICS? Sino | Ne gt; 7. HAVE YOU EVER BEEN A MEMBER OF, OR SUPPORTED, OR HAD ANY CONNECTIONS WITH A FOREIGN INTELLIGENCE ORGAN- IZATION OR ITS ACTIVITIES? = ¢ (Cllves. xX] NO IF ANSWER IS “YES*°, GIVE COMPLETE DETAILS. web. 8. LIST BELOW THE NAMES OF GOVERNMENT DEPARTMENTS, AGENCIES OR OFFICES TO WHICH YOU HAVE APPLIED FOR EM- A., STATE gE PRRT MENT, P4V AMEMCRA UNt0 i, C1VtL SERVICE, PLOYMENT SINCE 1940 C.D. HAVE CONDUCTED AN INVESTIGATION OF YOU, INDICATE THE NAME OF THE E INVESTIGATION. UNK. NOTE SPECIAL| [Uf your answer is *YES* to the following Questions 10, 11 or 12, provide the information requested for each INSTRUCTIONS | question on a separate, signed sheet and attach the sheet to this form in a sealed envelope. HAVE YOU, OR TO YOUR KNOWLEDGE HAS YOUR SPOUSE, EVER BEEN DETAINED, ARRESTED, INDICTED OR CON- ee OR ANY VIOLATION OF THE LAW OTHER THAN A MINOR TRAFFIC VIOLATION IN THE UNITED STATES OR IF SO, STATE NAME OF COURT, CITY, STATE, COUNTRY, DATE, NATURE OF OFFENSE AND DISPOSITION OF CASE IN ACCORDANCE WITH THE SPECIAL INSTRUCTION ABOVE. HAVE YOU EVER SEEN ARRESTED, COURT-MARTIALED OR OTHERWISE PUNISHED UNDER MILITARY LAW OR REG- ULATION? IF §0, DESCRIBE INCIDENT(S) AND PROVIDE DATE(S) OF GCCURRENCE ON SEPARATE SHEET IN AC- CORDANCE WITH SPECIAL INSTRUCTIONS ABOVE. n ARE THERE ANY UNFAVORABLE INCIDENTS IN YOUR LIFE, NOT MENTIONED ABOVE, WHICH MAY IN SUBSEQUENT INVESTIGATION, WHETHER YOu WERE DIRECTLY INVOLVED OR NOT, WHICH MIGH PLANATION? IF SO, DESCRIGE INCIDENT(S) AND PROVIDE DATE(S) GF OCCURRENCE ON SEPARA CORDANCE WITH SPECIAL INSTRUCTIONS ABOVE. SECTION XXV 1. NAME (Firet-Middie-Laat) ‘ 2. RELATIONSHIP PAULINE TUANITR OD RIG A EZ, Were 3. HOME ADDRESS (No., Street, City, Zone, State, Country) 4 HOME PHONE NO. 93g Ste. (78 St PEARINE S72), FLA. CEdag ~S- 834 %. BUSINESS ADDRESS (No., Street, Clty, Zone, Stete, Country) - INDICATE MAME OF FIRM OR|6. BUSINESS PHONE NO. & EXT. EMPLOYER, IF APPLICAGLE 7. 1M 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. a A- - ¥§ -
14-00000 - 16. @ [SECTION XXVI ° CERTIFICATION toy ‘ YOU ARE INFORMED THAT THE CORRECTNESS OF ANY STATEMENT MADE IN THIS APPLICATION ; WILL BE INVESTIGATED. sx 4 have read ond understand the instructions. | Certify that the foregoing answers are true and correct te the bes? of m knowledge and belief. | agree that Gny misstatement or omission as to material fact will constitute grounds for immediate dismissal or rejection of my application. | also understand thet any false statement made herein may be punishable by law (U.S. Code, Title 18, Section 1007}. 1. DATE OF SIGNATURES Seh, S, 166 / | 3. SIGNED AT (City and State) : : ™ < Mihm, FLR. NOTE: Use the following space for extra details. Reference ea ———— OTE OP t relates, sign your name at the end of the added material. If additional space is required use extra pages the same size as this page and sign each such page.