404-10117-10076 a se & < A PERSONAL HISTORY STATEMENT — (Appendiz 1) Listed below are names of organizations identified by the Attorney General, under his responsibility pursuant to Executive Ordér 10450, dated.27 April 1953, to Ust the names of each foreign or domestic. organization, association, movement, group or cambination.of persons which he designates as Totalitarian, Fascist, Communist, or subversive, or'as having adopted. or having shown # policy of advocating or approving the: commission. of acts af force or vio- lence to deny others their rights under the Constitution of the United: States, or as seeking te alter the form. of government. of the United States by unconstitutional means. Zach applicant or employee. and spouse (@ifany) must. review the following list of organizations for certification purposes,.and sign: om the last page. | Bostan. School for Marziet. Qtudies,. Boston, Massachusstts Bridges-Roberteon-Schmidt. Defense Committee Bulgarian American: People’s League of tha United States af America Action Committee ta. Free-Gpain Now Alsbamea. People’s. Baucations!. Association (see Communist Politi- eal Associations American Aneociation for Reconstruction in Yugoalavia,. Inc. Americum Branch: of: the Pedearsation of Greek Maritime Unions American Christian. Netionalist. Party American. Committee fier European: Workere: Belief: (see Goclalist California Carpatho-Russian: People's Goclety -Gentral. Council of Americam- Women of Croatian Descent, also . known. as. Central Council: of’ American Croatiam Women, Na- ‘ Gentzal. Japenese: Avsoriation. (Beikoku: Choe: Mippanjin: Kat) (Deuteche-Amerivanischs. Zinheitafront) China. Welfare Agmpeal, Inc. -Chopin Cultural Center ‘ Citizens Committes:-af the Upper West Side (New York City) Amertean Committes. for Spanish. Freedom American Committes.tor. tha. Settlement.of Jews in-Birohidjan, Inc. Clril: laberties Sponsertng Gommittes of Pitteburgh ‘Qivil Rights Congress and. ite affliated organizations. including: Civyl Rights. Gongrese for Texas Veterans Agsinst. Discrimination. of: Givil. Rights Congress: of Hew York Civil Righter Gongress. for Teaas (eee Civil Rights Congress) Columbians Comite Coomiinador Pro: Republica Espanola Comite Pro Derechos. Civiles (Sea: Puerto Rican Comite Pro Libertades Civiles) _Committes for-a Democratic. Par Eastern Policy ‘Committee for Constitutianal and. Political. Freedom . Committee. for: Nationalist. Action a Comomittee for Peace and Brotherhood Pestival in Philadelphia . Committees forthe Defenss.of the Pittaburgh. Bix Committee. for: the Negro -in the Arts Committee for the Protection of the Bill of Rights Cammittes for. World Youth: Friendship and Cultural Exchange Committee to Abolish Discrimination in Maryland (See. Congress Against. Diecriminmation; Maryland Congress Against Discrimination; Provisional Commitise to Abolish Discriminstion in the State of Maryland) Coramittes. to Aid the Fighting: South Association of Georgia: Klans Committes. to Defend Marie Richardson Association of.German: Nationale (Reichedeutechs Vereinigung) Committee to Defend the Rights and Freedom of Pittsburgh's Ausiand-Organization der N&DAP, Overseas Branch of Nazi Party : Political Prisoners: Commitres to Uphold the: Bill of Rights Batt Yorum: Commonwealth College; Mena, Arkansas Benjamin Davis Preedom Committes Communist Perty,. U. 4. A, ite subdivisions, subsidiaries, and Biack Dmgon Soatety adiliates American. Pollen. Labor Council American Pollah. League American Rescues Ship Mission (a project of the United American Spanish Aid Committee) ° American-Russian Fraternal Society American Russian Institute; New York, also:known ee the Ameri- ean Russian Institute for Cultural Relations with the Soviet Union American Bussien Institute;. Philadelphia @Asmerican Russian Institute of. Gan. Francisco American Russian. Institute of Gouthern California, Los Angeles American. Slay Congress American Women for Peace American. Youth . Congress American Youth for Democracy Armenian Progressive League of America Associated Klana of America FORM 444d USE PREVIOUS EDITIONS -i- ay
14-00000 Communist Political Association, tte eubdivisions, subaidiarics, and affiliates, including: Alabama People’s Educational Association Piecida Press and Educational League Okisboma League for Politics] Education People’s Educational and Press Association of Texas Wirginia League for People’s Education Congress of the Unemployed Qonnecticut Committees to Aid Victims of the mith Act Connecticut State Youth Conference Gouncii for Joba, Relief and Housing Croatian Benevolent Fraternity Dal Kippon Butekw Kai (Military Virtue Boclety of Japan or Mu- tary Art Society of Japan) Dally Worker Press Chub Panicle Defense Commitice Dente Alighieri Bociety (between 1635 and 1940) Dennala Defense Committee Detroit Youth Assembly Bisinore Progressive League Emergency Conference to Save Spanish Refugees (founding body of the North American Spanish Ald Committee) Everybody’s Gommittes to Outiaw War Pumilies of the Baltimore Bmith Act Victims Pemilies of the Gmith Act Victims Federation of Italian War Veterans tn the U. 5. A. Inc. (Associa- gione Nesionale Combsattentt ftallant, Pederagione degli Stati Uniti @Aamerica) Finolsh-Americen Mutual Aid Bociety Florida Presa and Educational League (see Communist Politica) Asaociation) Prederick Dougiass Educations] Center Freedom Stage, Inc. . Priends of the New Germany (Preunde des Neuen Deutschiands) Priends of the Soviet Union Garibaldi American Fraternal Society George Washington Carver School, New York City German-American Bund (Amerikadeutecher Yolkabund) German-American Republican League German-American Vocational League (Deutache-Amerikanische Berufsgemeinschaft) Guardian Club ® Bariem Trade Union Council Bawall Civil Liberties: Committes Hetmusha Kai, aleo known as Nokubel Heleki Gimsusha Kal, Zaibel Nihnonjin, Helyaku Gimusha Kal, and Zalbel Heimusha Bal (Jap- anese Residing im America Military Conscripta Association) Flelientc-American Brotherhood Winede Kai (Imperial Japanese Reservists) Binomearu Kei (Rising Sun Flag Gociety--a group of Japanese War Veterans) . Hokubel Zaigo Shoke Dan (North American Reserve Officera Asso- ciation) Hollywood Writers Mobilization for Defense Hungerian-American Council for Democracy Hungarian Brotherhood Idaho Pension Union Independent Party (Seattle, Washington) {See Independent People’s Party) Tuadependent People’s Party (Gee Independent Party) industrial Workers of the Worid international Labor Defense International Workers Order, ite subdivisions, subsidiaries and amMliates Japanese Aseociation of America Japanese Overseas Central Society (Kaigal Dobo Ohuc Kail) dapaness Overseas Convention, Tokyo, Japan, 1940 Jepaness Provective Association (Recruiting Organization) Jefferson School of Gocial Science, New York City dewiah Culture Bociety Jewish People’s Committee dewleh Poople’s Fraternal Order dikyoku linkal (The Committes far the Crisis) dohnson-Porest Group (See Johnsonites) dohnsonites . (Gee Johneon-Forest Group) goint Anti-Pascist Refugee Committes Joint Coumcll ef Progressive Italian-Americens, Inc. doseph Wedemeyer School of Social Gclence, Bt. Louls, Missourt Eibel Beinen Eal (Association of U. 8. Citizens of Japanese AR- cestry who have returned to America after studying im Japan) Enights of the White Camelita Ku Klux Kian Kyfhseuser, also known as Kyfthacuser League (Kyffhacuser Bund), Kyfhacuser Pellowship (Kyfthacuser Kameredachaft) Kyfhseuser War Relief (Kyfhaeuser Ertegahilfswerk) Labor Council for Negro Righta Labor Research Association, Inc. Labor Youth League League for Common Sense League of American Writers Lictor Bociety (Italian Black Shirts) Macedonian-American People's League Rario Morgantini Circle Maritime Labor Committees to Defend Al Lannon Maryland Congress Against Discrimination (See Committee to Abolish Discrimination in Maryland) Massachusetts Committee for the Bill of Rights Massachusetts Minute Women for Peace (not connected with the Minute Women of the U. & A., Inc.) Maurice Braverman Defense Cammittee Michigan Civil Rights Federation Michigan Coumell for Peace Michigan School of Social Science Ranka Telkoku Gunyuden (Imperial Military Friends Group or Southerm California War Veterans) National Association of Mexican Americans (also known as Asocia- cion Nacional Mexico-Americana) . Rational Blue Star Mothers of America (not to be confused with the Blue Star Mothers of America organized in February 1942) Rational Cammittes for Freedom of the Press National Committee for the Defense of Political Prisoners National Committee to Win Amnesty for Bmith Act Victimg National Committees to Win the Peace National Conference on American Policy in China and the Far East (a Comference called by the Committee far @ Democratic Par Eastern Policy) National Council of Americans of Croatian Descent National Council of American-Soviet Friendship National Federation for Constitutional Liberties National Labor Conference for Peace Nations} Negro Congress National Negro Labor Council Netionalis? Action League PRIOR eT Seppe linet fygee
Nationalist Party of Puerto Rico Nature Priends of America {since 1935) Hegre Labor, Victory Committee Kew Committee far Publications Kichibe’ Kogyo Kaisha (The Great Pujil Theatre) North American Committees to Aid Spenisah Democracy Herth American Gpanish Ald Committee orth Pailedelphis Forum Korthwest Japanese Association Ohic Gchool of Social Sciences Oxlahoma Conomittes to Defend Political Prisoners Okiahoma League for Political Education (see Communist Politi- Pacific Northwest Labor Gchool, Beattie, Washington Pale Alto Peace Club Partide del Pucbio of Panama (operating in the Canal Zone) Peace Information Center Peace Movernent of Ethiopia People’s Drama, Inc. People’s Educational and Press Association of Texas (see Commu~ mist Political Association) People’s Educationsl Association {incorporated under name Loe Angeles Educational Association, Inc.), also Known as People’s Béaucational Center, People’s University. People’s School Peopie’a Institute of Applied Religion Peoples Programs (Seattle, Washington) People’s Radio Foundation, Inc. People’s Rights Party Philadelphia Labor Committes for Negro Righte Philadelphia Gehool of Goctal Eclance and Art Phote League (New York City) Pittsburgh Arte Club Political Prisoners’ Welfare Committee Proletarian Party of America Protestant War Veterans of the United Btates, Inc. Provisional Committee of Citizens for Peace, Bouthwest Area Provisional Committes om Latin American Affairs Provisional Committee to Abolish Discrimination ta the State of Maryland (Bee Committes to Abolish Discrimination in Maryisnd) Puerto Rican Comite Pro Libertades Civlles (CLO) {Gee Comite Pro Derechos Civiles) Puertorriquencs Unidos (Puerto Ricans United) Quad City Committee for Peace Queensbridge Tenants League Revolutionary Workers League Romanian-Americen Fraternal Bociety Russian American Goclety, Inc. Sakura Kai (Patriotic Gociety. oF Cherry Association — compcsed ef veterans of Buseo-Japaness War) Bamuel Adams School, Boston. Massachusetts Gants Barbara Peace Porum Gchappes Defense Committee Schneiderman-Darcy Defense Oommittee School of Jewish Btudies, New York City Beattie Labor School, Beattie, Washington Berbian-American Fraternal Society , Gerdian Videvdan Council . -. Ghinto Temples (limited to State Shinto abolished im 1945 Blovak Workers Society Glovenian-Americen National Oouncil Gocialist Workers Party, including American Oommittes for Buro- pean Workers’ Relief? @okeku Eal (Patheriand Soclety) Southern Negro Youth Congress Guike Sha (Reserve Officers Association, Los Angeles) Byracuse Women for Peace Tom Paine School of Social Gcience, Philedelphia, Pennsyivanis Tom Paine School of Westchester, New York Trade Union Committes for Peace (Gee Trade Unionists for Peace) Trade Unionists for Peace (See Trade Unionists for Peace) Tri-Btate Negro Trade Unien Council Ukrainian-American Fraternal Union Union ef American Crostians Union of Rew York Veterans United American Spanish Aid Committes United Committee of Jewish Gocieties and Landsmanachaft Fed- erations, aleo known as Coordination Gommittes of Jewish Landsmanschaften and Praternal Organizations United Committee of South Slavic Americans Wnited Defense Council of Southern California United Harlem Tenants and Consumers Organization United May Day Committee United Negro and Allied Veterans of America Veterans Against Discrimination of Civil Righte Congress af New York (eee Civil Rights Congress) Veterans of the Abraham Lincoln Brigade Virginia League for People’s Education (see Communist Political Association) Voice of Preedom Committee Walt Whitman School ef Gocial Science, Newark, New Jersey Washington Bookshop Association Washington Committee for Democratic Action Washington Committee to Defend the Bul of Rights Washington Commonwealth Federation Washington Pension Union Wisconsin. Conference on Gocial Legislation Workers Alliance (since April 1934) Viddisher Kultur Ferband Young Communist League Yugoslar-American Cooperative Home, Inc. Yugoalay Geamen’e Club, Inc. oe . : Scars eae no
14-00000 eo iF = ete . 2 eet DO NOT USE THIS SPACE ~ issUED BY * PERSONAL HISTORY STATEMENT —— THIS DATE (Pill in) September 6, 1961 INSTRUCTIONS AGaF 4 = 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 | GENERAL PERSONAL AND PHYSIC A 1. FULL NAME (Laat-Firat-Middle) 2. AGE fi 3. SEX FLORES, Daniel F 26 MALE FEMALE & HEIGHT §. WEIGHT ° 6 COLOR OF EYES 7. COLOR OF HAIR 8. PE COMPLEXION %. TYPE BULLD 51 gn 165 pds. Brown Black } Dark Medium 10. SCARS (Type and Location) Right cheek, one-half inch scaP; left> upper lip, one- rter inch scar: both received playing football 11. OTHER DISTINGUSHING PHYSICAL FEATURES 3 None 12, CURRENT ARPDRESS (No., Street, City, Zone. State and Country) . 13. PERMANENT ADDRESS (No., Street, City, Zone, State and = countey) AND PHONE NO. : e ¢ BS ~ “howe TH ashington 6, D. ©. ~ Washington 8, D.C. &. RENT PHONE NO. 18. OFFICE PHONE NO. & EXT. 16. LEGAL RESIDENCE (State, Territory or Country) oS None Washington, District of Columbia 1?. NICKNAMES 18. OTHER NAMES YOU HAVE USED Dan None 19. INDICATE CIRCUMSTANCES (Including Length of Time) UNDER WHICH YOU HAVE EVER USED THESE NAMES. uaintances - twelve years 26. IF LEGAL CHANGE, GIVE PARTICULARS (Where and by What Authority). NA @ |SECTION HI POSITION DATA 1. INDICATE THE TYPE OF WORK OR POSITION FOR WHICH YOU ARE APPLYING 1% ‘Any phase of communications; administration; or personnel work, 2. INDICATE THE LOWEST ANNUAL ENTRANCE SALARY YOu WILL B. E EMPLOYMEN ACCEPT (You will not be considered for an position with @ lower DATE AVAILABLE FOR v T entrance salery). $ 250.00 - Immediatel & INDICATE YOUR WILLINGNESS TO TRAVEL OCCASIONALLY FREQUENTLY CONSTANTLY OTHER: &. INDICATE YOUR WILLINGNESS TO ACCEPT ASSIGNMENT IN THE FOLLOWING LOCATIONS (Check (X) each item applicable) WASHINGTON, 0.C. ANYWHERE IN U.S. CERTAIN LOCATIONS ONLY (Specify): OUTSIDE CONTINENTAL U.S. 6. INDICATE WHAT RESERVATIONS YOU WOULD PLACE ON ASSIGNMENTS GUTSIDE THE WASHINGTON, D.C. AREA. I would be willing to travel within the United States provided said travel would not involve a permanent move whereby my legal residence would be changed. However, it is my wish to live overseas on a permanent basis. . ny FORM 444 USE PREVIOUS EDITION. is IOY COONEY 1- AG a 43
14-00000 >», 8 ot co F r f. Section SSSSSCSC~C“~“‘“‘“‘“*~*‘“*CSTIENSHIR 1. DATE OF -BIRTH 2. PLACE OF BIRTH (City, State, Country) Jf 3. PRESENT CITIZENSHIP (Country) 9R5 [0 Texas United States of America g ~ CITIZENSHIP ACUDINED E 5. OTE NATURAL- 6. NATURALIZATION CERTIFICATE NO. PX[ea [ [wanmiace | Tornen Gree | “NA NA 7. COURT ISSUING NATURALIZATION CERTIFICATE 8. ISSUED AT (City, State, Country) NA NA 9. HAVE YOU HELD PREVIOUS NATIONALITY 19. iF YES, GIVE NAME OF COUNTRY NA 41, GIVE PARTICULARS CONCERNING PREVIOUS NATIONALITY. NA 12. HAVE YOU TAKEN STEPS TO CHANGE PRESENT C(TIZENSHIP Nd if YOU HAVE APPLIED FOR U.S. CITIZENSHIP, WHAT IS PRESENT STATUS OF YOUR APPLICATION (Firat Papere, Ete.)? NA 1S. DATE OF ARRIVAL IN U.S. NA 18. LAST U.S. VISA (No., $4. 16. PORT OF ENTRY NA 17. ON PASSPORT OF WHAT COUNTRY NA NA Type, Place of Issue) NA @ | SECTION iV EDUCATION e Tas TAN WGN SCHOOL GRADUATE —~—”~*~“‘*‘“~*d:C*d EWS WEAR OR COLL EE NO DESRER —Traane usin of CommERCiAL senooL canbusTe | [enabuaresTuoy LEADING TOMIeHEROEeREE 2. ELEMENTARY SCHOOL : 2 aoe) 1. NAME OF ELEMENTAR SCROOL* - ADDRESS (Ci p State, Country) BSEM/QTR HOURS (GSpecity) SECTION IV CONTINUED TO PAGE 3 gence ected AEC SESTOSESP SRS EE FS ET . ~~ - ® Se = . = = &
14-00000 ecm ei ite SECTION [V CONTINUED FROM PAGE 2 A ; ED IN ITEM # WHICH REQUIRED SUBMISSION OF A WRITTEN THESIS, INDICATE THE TITLE & TRADE, COMMERCIAL AND SPECIALIZED SCHOOLS NAME AND ADDRESS OF SCHOOL STUDY OR SPECIALIZATION | from [| TO | | MONTHS | 7. MILITARY TRAINING (FULL TIME DUTY it SPECIALIZED SCHOOLS SUCH AS ORDNANCE, INTELLIGENCE, COMMUNICATIONS, ETC.) ro | From ps, Security Guard yon yen _| q aleacde a Odd LAS, . . . ) 8. OTHER EDUCATIONAL TRAINING NOT INDICATED ABOVE. . Weapons Training in Marine Corps. Acted as partisan during cold weather training at Bridgeport, California (Pickle Meadows = USMC). + 3 @ | SECTION V FOREIGN LANGUAGE ABILITIES COMPETENCE - IN ORDER LISTE 1, LANGUAGE | Read, WeWriter SSpeak (Liat below each language in which you poesese any degree EQuiv- 2 ALENT of competence. Indicate your — To 5 Proficiency to Read, Write or NATIVE OB each. Speak by placing a check (X) FLUENCY in the appropriate box(es). Ou HAVE INDICATED FLUENCY FOR A LANGUAGE HAVING SIGNIFICANT DIFFERENCES IN SPOKEN AND WRITTEN FORM, EX- IN YOUR COMPETENCE THEREIN. NA 4 DESCRIBE YOUR ABILITY TO DO SPECIALIZED LANGUAGE WORK INVOLVING VOCABULARIES AND TERMINOLOGY IN THE SCIEN- TIFIC, ENGINEERING, TELECOMMUNICATIONS, MILITARY, AND OTHER SPECIALIZED FIELDS. Could act as literal interpreter at almost any level. 8. 1F YOU HAYE NOTED A PROFICIENCY IN LANGUAGE, WOULD YOU BE WILLING TO USE THIS ABILITY IN ANY POSITION FOR WHICH YOU MIGHT BE SELECTED? .
14-00000 * 5 £ @ | SECTION VI GEOGRAPHIC AREA KNOWLEDGE AND FOREIGN TRAVEL i. ° OUNTRIES IN WHICH YOU HAVE A ROADS, INDUSTRIES, POLITICAL PARTIES, ETC. oA nENCE DATES ano EVEL PLACE OF STUDY Marine Security Guard - American Embassy - Bolivia and Peru Vacation ~ Chile; Argentina; Uruguay; Panama ® TYPING AND STENOGRAPHIC SKILLS 5 wpm | None [[enees | [srecowmirine | [srenorvee | [ornen (pecity) 2. INDICATE OTHER BUSINESS MACHINES WITH WHICH YOU HAVE HAD OPERATING EXPERIENCE OR TRAINING (Comptometer, Himeogmph, Card Punch, Etc.). Thermofax, mimeograph, switchboard @ | SECTION Vill SPECIAL QUALIFICATIONS 3 % eae HOBBIES AND SPORTS IN WHICH YOU ARE ACTIVE OR HAVE ACTIVELY PARTICIPATED. INDICATE YOUR PROFICIENCY Foot ball - good Basketball - fair Swimming | > .= good Reading ow average Contract.Bridge - very good 2. INDICATE ANY SPECIAL QUALIFICATIONS RESULTING FROM EXPERIENCE OR TRAINING WHICH MIGHT FIT YOU FOR A PARTICULAR POSITION OR TYPE OF WORK. None to my knowledge 3. 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 (Indi- cate CW epsed, saending and receiving), OF FSET PRESS, TURRET LATHE, SCIENTIFIC AND PROFESSIONAL DEVICES. None SECTION VII CONTINUED TO PAGE 5 — Fa
14-00000 mre SSE SECTION VIll CONTINUED FROM PAGE 4 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.? | jves g ]NO S$. 1F YOU HAVE ANSWERED “YES® TO ABOVE, INDICATE KIND OF LICENSE AND STATE ISSUING LICENSE (Provide License Regiatry Number, if known). NA 6. FIRST LICENSE OR CERTIFICATE (Year of lasue) 7. LATEST LICENSE OR CERTIFICATE (Yeer of Ilsaue) 8. LIST ANY SIGNIFICANT PUBLISHED MATERIALS OF WHICH YOU ARE THE AUTHOR (Do NOT eubmit copiss unless requested). INDICATE THE TITLE, PUBLICATION DATE, AND TYPE OF WRITING (Nor-Fiction or Scientific articles, General Intereat aubjecta, Novels, Short Stories, Ete). | None 9. INDICATE ANY DEVICES WHICH YOU HAVE INVENTED AND STATE WHETHER OR NOT THEY ARE PATENTED. None 10. LIST PUBLIC SPEAKING AND PUBLIC RELATIONS EXPERIENCE. Have spoken in my father's church and other churches approximately 150 times. Met and assisted public in Embassies during my tour of with the Marine Security Guard. 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. None SECTION 1X EMPLOYMENT HISTORY NOTE: (LIST LAST POSITION FIRST.) Indicate chronologicél history of employment for past 15 years. Account for all periods including casual employment and all periods of unemployment. Giveaddress and state what you did during periodsof wmnemployment. List all civilian employment by a foreign Government, regardless of dates. In completing item 9, “De- acription of Duties® consider your experience carefully and provide meaningtul, objective statements, 1. INCLUSIVE DATES (From and To - By Mo. and Yr.) 2. NAME OF EMPLOYING FIRM OR AGENCY From 1949 to 19 3. ADDRESS (No., Street, City, State, Coumtry) do S$. NAME OF SUPERVISOR cerwsr-oR ADE (If Federal Service) $100,00 [Per month OuUNntaInN Bs enda %. DESCRIPTION OF DUTIES Employee at soda counter 1G. REASONS FOR LEAVING - To participate in school events (football). SECTION IX CONTINUED TO PAGE 6 -3- SF
14-00000 . Ls SECTION IX CONTINUED FROM PAGE 5 1. INCLUSIVE DATES (From and To - By Mo. and Yr.) 2. NAME OF EMPLOYING FIRM OR AGENCY July 1954-June 1955 \Grocery Store 3. ADDRESS (No., Street, City, State, Country) 5 oF . ° Texas 4. KIND OF BUSIN §. NAME OF SUPERVISOR Grocery Store | Mr [| 1) 06 6. TITLE OF JOB 8 CLASS. GRADE (If Federal Service) Butcher 330,00 [ren Week 9. DESCRIPTION OF DUTIES Slaughtering and preparing meat for sale as well -as actual selling. 10. REASONS FOR LEAVING To attend college 2. MAME OF EMPLOYING FIRM OR AGENCY 1. INCLUSIVE DATES (From and To - By Mo. and Yr.) oy, é. TITLE OF JOB | 7. SACKRY-OF EARRINGS — vrti-ASS. GRADE (if Federal Service) Painter's Assistant Ps 35,00 [rer week | 9. DESCRIPTION OF DUTIES Painted dormitories in the Academy no © 6. 10. REASONS FOR LEAVING To attend school 1. INCLUSIVE BATES (From and To - By Mo. and Yr.) September, 1956 = July, 1957 . 3. ADDRESS (No., Street, City, State, Countey) 9Texas ; Clothing Store . . 6. TITLE GF JOB Sales Clerk 9. DESCRIPTION OF DUTIES Assisted customers in selecting and buying goods. 10. REASONS FOR LEAVING -To join the Marine Corps. 2. MAME OF EMPLOYING FIRM OR AGENCY s Marine Corps 1. INCLUSIVE DATES (From and To - By Mo. and Yr.) ly 26, 19 - 3. ADDRESS (No., Street, City, State, Country) Marine Corps Schools, Quantico, Virginia 4 KIND OF BUSINESS 5. NAME OF SUPERVISOR Military _. - |Col. John Magruder 8. TITLE OF Jo8 8. CLASS. GRADE (If Federal Service) Marine Corps Museum Attendant [s 100.00 |rermonth Cpl. (E-l) SECTION IX CONTINUED TO PAGE 7 _ SH Ir)
14-00000 . SECTION IX CONTINUED FROM PAGE 6 8. DESCRIPTION OF DUTIES Acted as guide to all visitors entering Museum, explaining Marine Corps history, etc. Also on several occasions acted as interpreter for visiting military personnel from Latin America, 10. REASONS FOR LEAVING Dis charged 1. INCLUSIVE DATES (From and Te - By Mo. and Yr.) . 2. NAME OF EMPLOYING FIRM OR AGENCY July 28, 1961 - August 30, 1961) 00 3. ADORESS (No., Street. City, State, Country) p> Toe “Ke - 6. TITLE OF JOB 3. SALARY OR EARNING 8. CLASS. GRADE (If Federal Service) Laborer rer Hour @. DESCRIPTION OF DUTIES Handyman for Company OD Construction . 10. REASONS FOR LEAVING Temporary work while seeking permanent employment ; 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 3. NAME OF SUPERVISOR 6. TITLE OF JOB 7. SALARY OR EARNINGS 8. CLASS. GRADE (If Federal fee 7 9. DESCRIPTION OF DUTIES 10. REASONS FOR LEAVING 8. IF PRIOR SERVICE WITH THE FEDERAL GOVERNMENT IS NOTED ABOVE, INDICATE THE HUMBER OF YEARS CREDITABLE TOWARD U.S. CIVIL SERV[CE RETIREMENT, IF KNOWN. 7 1/2 years 9. HAVE YOU EVER BEEN VISCHARGED OR ASKED TO RESIGN FROM ANY POSITION. HAVE YOU LEFT A POSITION UNOER CIRCUMSTANCES WHICH YOU DESIRE TO EXPLAIN? [_]yes [AJNO IF YOUR ANSWER TO EITHER OR BOTH QUESTIONS IS “YES*, GIVE DETAILS ‘ Honorably discharged from United States Marine Corps.
SECTION X MILITARY SERVICE 1. CURRENT DRAFT STATUS : | x | ves| 2. sevecrive service CLASSIFr | 3. SELECTIVE SERVICE NO. 1. ARE YOU REGISTERED FOR THE DRAFT UNDER THE UNIVERSAL MILITARY TRAINING AND CATION SERVICE ACT OF 1948 (As amended) | [NO | ~A d 4. IF DEFERRED, GIVE REASON 5, LOCAL ORAFT BOARD NO. OR DESIGNATION AND ADOB NA bof 2. MILITARY SERVICE RECORDjy{( = NN Texas CHECK (X) AS MARINE AIR COAST NATIONAL] AIR NAT*L| FOREIGN ORGAN, OR MIL. APPROPRIATE ARMY NAVY | cores | Force | GUARD suarn | cguarp | SERVICE (Specify): None ePrsonne a CMS =. O 3. DATE SEPARATED FROM EXTENDED ACTIVE OUTY (Pact servicd| & TOTAL LENGTH OF EXTEN . FORCES (Peat and current ee: 2 July 961 years 5. DATE ENTERED PAST SERVICE CURRENT SERVICE 6. TOTAL LENGTH OF ACTIVE DUTY IN FOREIGN MILITARY OR- ACTIVE DUTY op GANIZATION DEO ACTIVE DUTY IN U.S. ARMED rvi oe) : 26 July,1957 —~ 7. RANK, GRADE OR | PAST SERVICE CURRENT SERVICE &. SERVICE, SERIAL OR FILE NUMBER (If now serving, provide cur RATE eee rent number) Cpl. (E- 9. PRIMARY MILITARY OCCUPATIONAL PAST SERVICE CURRENT SERVICE SPECIALTY (Mos or Designator) AND TITLE Olul = Chief Clerk 1G. SECONDARY MIL. OCCUPATIONAL PAST SERVICE CURRENT SERVICE SPECIALTY (Moe or Designates) AND TITLE None tf. BRIEF DESCRIPTION OF MILITARY DUTIES (indicate whether applicable to past or current service) Past Service: Clerk - Maintained personnel service records, 2 years as Security Guard in the American Embassies in La Paz, Bolivia and Lima, Peru. 12. CHECK (X) TYPE OF SEPARATION FROM ACTIVE DUTY |X) HONORABLE DISCHARGE | RETIREMENT FOR SERVICE UNDUE HARDSHIPS K | RELEASE TO INACTIVE DUTY | RETIREMENT FOR COMBAT DISABILITY - RETIREMENT FOR AGE | RETIREMENT FOR PHYSICAL DISABILITY 13. CHECK (X) COMPONENT IN WHICH YOU SERVED x | REGULAR LA RESERVE (Including the National and Air National Guard) OTHER (Including AUS) 3. MILITARY RESERVE, NATIONAL GUARD AND ROTC STATUS 1. DO YOU NOW HAV YES 2. ARE YOU NOW A MEMBER OF THE VES 3. ARE you eer A MEMBER OF YES RESERVE STATUS? NAT’L. GRD. OR AIR NATEL. THE ROT | __[no | _Gro. [wo | |X [xo | VE A ECK COMP D.? 4. iF YOU Ha NSWERED “YES° TO ITEMS 1,2 OR 3 ABOVE, CH ONENT MEMBERSHIP BELOW |___brmy X Parinecorrs [NATIONALGUARG [COASTGUARD] | NAVY ROTC INDICATE ROTC CATEGORY NUM BER | pave ainForce | [air NAT'L.GUARD, | ARMY ROTC | [AIR FORCE ROTC S. CURRENT RANK, GRADE OR 6. DATE OF APPOINTMENT IN CURRENT |7. EXPIRATION DATE OF CURRENT RESERVE OBLIGA- N PATE Col. (E- May, 1959 January 20, 1962 8. CHECK (X) CURRENT RESERVE CATEGORY | [READY Reserve] _ |stanosy(Active)| ¥ | STANOBY(Inactive)| | RETIRED 9. PRIMARY MILITARY OCCUPATIONAL SPECIALTY (Moe or Desig- |10. SECONDARY MILITARY OCCUPATIONAL SPECIALTY (Mos or Dea- netor) AND TITLE : . ignates) AND TITLE « , None 11. BRIEF DESCRIPTION OF MILITARY RESERVE DUTIES > 2 None 12, ARE YOU CURRENTLY ASSIGNED OR ATTACHED 13. IF YOU HAVE ANSWERED “YES® TO ITEM 12, GIVE UNIT OR AGENCY TO A RESERVE, NAT'L. GUARD OR ROTC TRAIN- ANO ADDRESS aa ING UNIT ’ x | 16. HAVE YOU A MILITARY MOBILIZATION ASSIGN- | YES | 15. iF you HAVE ANSWERED "YES" TD ITEM t4, GIVE UNIT OR AGENCY MENTT : XxX [No] HD ADDRESS : 16. INDICATE. TOTAL MILITARY SERVICE] YEARS MONTHS 17. WHERE ARE YOUR SERVICE RECORDS KEPT? OR LONGEVITY PURPOSES INCLUD ING ACTIVE AND INACTIVE DUTY 7 7 Headquarters Mar*ne Corps, Washington alPy
1, PRESENT STATUS (Single, Married, Widowed, Separated, Divorced, or Annulled) sPeciFY: Married tt. CURRENT ADORESS (Give lest address, ii deceased) OP a ae SECTION XI - FINANCIAL STATUS 1-ARE YOU ENTIRELY DEPENDENT ON YOUR SALARY? {_lves EX] no 2. IF YOUR ANSWER IS “NO” TO THE ABOVE, STATE SOURCES OF OTHER INCOME Wife's income 3. BANKING INSTITUTIONS WITH WHICH YOU HAVE ACCOUNTS NAME OF INSTITUTION ADDRESS (City, State, Country) eoWe venue , The Bank of California, N.A. Portland, Oregon , 15 and H Streets, N.W., nion Trust Compan Washington, D.C. 4. HAVE YDU EVER BEEN IN, OR PETITIONED FOR, BANKRUPTCY, [} ves [at] no 5. 1F YOUR ANSWER IS “YES” TO THE ABOVE, GIVE PARTICULARS, INCLUDING COURT AND DATE(S) 6. GIVE THREE CREDIT REFERENCES IN THE UNITED STATES ° NAME * ADDRESS (No., Street, City, State) 1310 S.W. ¥ il rect, General Motors Acceptance Corp. Portland 5, Oregon P.O. Box 7 ? Gulf Oil Corporation Atlanta 9, Georgia 917 Caroline Steet, Ninde Furniture Compan Fredericksburg Virginia 7.00 YOU RECEIVE AN ANNUITY FROM THE UNITEO STATES OR DISTRICT OF COLUMBIA GOVERNMENT UNDER ANY RETIREMENT ACT, PENSION, OR COMPENSATION FOR MILITARY OR NAVAL SERVICE? C) ves fx] NO 6. 1F YOUR ANSWER 1S ““YES*' TO THE ABOVE QUESTION, GiVE COMPLETE DETAILS 9. DO YOU HAVE ANY FINANCIAL INTEREST IM, OR OFFICIAL CONNECTIONS WITH NON-U.$. CORPORATIONS OR BUSINESSES; OR IN OR WITH U.S. CORPORATIONS OR BUSINESSES HAVING SUBSTANTIAL FOREIGN INTERESTS? ["] ves , NO (If enewer “YES”, furnizh details on separate sheet.) SECTION XII MARITAL STATUS 2.STATE DATE, PLACE, AND REASON FOR ALL SEPARATIONS, DIVORCES OR ANNULMENTS 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. 3. NAME (First) : (Middle) (Maiden) -~(Last) + 7% . Flores 4 STATE ANY OTHER NAMES EVER USED INDICATE CIRCUMSTANCES (Including length of time) UNDER WHICH ANY GF THESE NAMES WERE USED. IF LEGAL CHANGE GIVE PARTICULARS (Where and by what authority). USE EXTRA SPACE PROVIDED ON PAGE 16 OF THIS FORM TO RECORD THIS INFORMATION. 8. GATE OF MARRIAGE - - | 7 PLACE OF MARRIAGE (City, State, Country) - November il, 1960 7. HIS (OR HER} ADDRESS BEFOR Br. , City, Seate, Country) American Embass {o 8. LIVING 9. DATE OF DEATH 10. CAUSE OF DEATH X i ves NO a. Washington 8,-D.C. 12. DATE OF BIRTH 18. PLACE OF BIR (City, State, Courtiry) 4. CITIZENSHIP January 31, 1935 Portland, Oregon nited States of : SECTION XII CONTINUED TO PAGE 10 -9- S57?
‘ Gea by * -10- SECTION Xil CONTINUED FROM PAGE 9 . 14. IF BORN OUTSIDE U.S. - DATE OF ENTRY 1S. PLACE OF ENTRY 16. FORMER CITIZENSHIPIS) Countryfies)? 7. BAe tics CITIZENSHIP | 18. WHERE ACQUIRED (City, State, Country) NA NA NA 19, OCCUPATION 20. PRESENT EMPLOYER (Also give former employer, or if spouse deceased or Legal Secretary’ : fh 06 Former: Department of State t. EMPLOYER'S OR BUSINESS ADDRESS (No., Street, City, State, Country) 22. DATES OF MILITARY SERVICE (From and fo - Sy Mo. and Yr.) None 23. BRANCH OF SERVICE - 24, COUNTRY WITH WHICH MILITARY SERVICE AFFILIATED 25. DETAILS OF OTHER GOVERNMENT SERVICE, U.S. OR FOREIGN Pong ign Service - Jan., 1958 - Oct , a9 1960: Civil Service - April 1961 - June 1961 SECTION XH CHILDREN AND OTHER DEPENDENTS e 1. PROVIDE THE FOLLOWING INFORMATION FOR ALL CHILDREN AND DEPENDENTS 2. NUMBER OF CHILOREN (Including etep- 3. NUMBER OF OTHER DEPENDENTS (Inchsding spouse, and edo; parents, etep-parents, sister, etc.) WHO DEPEND ON DNMAR Dt Nera ae AcE. VOU FOR AT LEAST 50% OF THEIR SUPPORT, OR UNMARRIED, UNDER 21 YRS. OF AGE, LL Fe CHILOREN OVER 21 YRS. OF AGE WHO ARE NOT AND NOT SEL F-SUPPORTING. SEL F-SUPPORTING. SECTION XIV FATHER (Give same infomation, for Stepfather and/or Guardian on a separate sheet) @ 2. LIVING 3. DATE, OF DEATH 4 CAUSE OF DEATH x [ves F [xe | INDICATE CIRCUMSTANCES (Including 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. {. FULL NAME (Last-Firet-Middle) NOES GURRENT ADDRESS - 9. CITIZENSHIP .19., DATE U.S. CITIZENSHIP _ ACQUIRED 2. FORMER CITIZENSHIP(S) Mexican tS. OCCUPATION Baptist Minister EMPLOYER'S BUSINESS ADDRESS OR FATHER’S BUSINESS ADORESS IF SELF-EMPLOYEO ([Country(iea)7 C3 16. MILITARY SERVICE (From-and BATES O owledge never a : SY Blof
» “| SECTION XV MOTHER (wive same information i. FULL NAME (Last-Firet-Middle) 2. ING 3. DATE OF DEATH Flores oO s\¥ Xj} 6 June 1939 8. STATE OTHER NAMES SHE HAS USED None to knowledge 6. CURRENT ADDRESS - GIVE LAST ADDRESS, IF DECEASED (No., Street, C INDICAT ev USEDAT and what a FORMATO R mother on separate sheet) 4. CAUSE OF DEATH Unknown IRCDMST ANCES (inckeing length of time) UNDER WHICH SHE HAS  Texa 7. OATE OF BIRTH 8 PLACE OF BIRTH ty, State, Country, eptember 20, 1904 Mier y Noriega, Nuevo Leon, Mexico tate, Country) SE NAMES. 1F LEGAL CHANGE, GIVE PARTICULARS (Where ority), USE EXTRA SPACE PROVIDED ON PAGE 16 OF THIS THIS INFORMATION. . NS exican 14. WHERE ACQUIRED (City, State, C NA 16 PRESENT EMPLOYER (Give last employer, if Mother ie deceased of unemployed, 20. COUNTRY NA 10. IF BORN OUTSIDE U.S.- DATE OF ENTRY if. PLACE OF ENTRY Unknown Unknown 12. FORMER CITIZENSHIPIS) /Country(ies)7 18. DATE U.S. CITIZENSHIP NA ACQUIRED NA 18. OCCUPATION Housewife NA 17. EMPLOYER'S BUSINESS ADDRESS OR MOTHER'S BUSINESS ADDRESS IF SELF EMPLOYED- NA 18 DATES OF MILITARY SERVICE (Prourand-To) 19 BRANCH OF SERVICE NA NA 21. DETAILS OF OTHER GOVERNMENT SERVICE, U.S. OR FOREIGN NA SECTION XVI BROTHERS AND SISTERS (Including Half-, Step- and Adopted Brothers and Sisters) 1. FULL NAME (LastF iret-Riddie) ob St, City, Zone, State, Country) ‘Texas 1. FULL. NAME (Cast Fires Middie) o& 4. CURRENT ADDRESS (No., Streei, City, Zone, State, Country) 2. RELATIONSHIP Sister 2. RELATIONSHIP Sister Texas TFULT NAME (Last F Gar male) 6 9 4. CURRENT ADDRESS (No., Street, City, Zone, State, Camtry) 2. RELATIONSHIP Sister Texas ?. FULL NAME (Laet-Firat-Middie) 4|_Flores 4 CURRENT AD 3 eb, Gi @, State, Country) 2. RELATIONSHIP Brother Texas 4. CURRENT A O, Street, City, Zane, Siate, Country) 2. RELATIONSHIP -Brother Texas 2. RELATIONSHIP 6 Sister 4 CURRENT ADDRESS (No., Speeet, City, Zone, State, Country} Virginia . FUCC NAME (Leet? ai-Middia) 2. RELATIONSHIP Flores 06 - Brother 4 CURRENT A ft, City, Zone, State, Country) Deceased 1. PULL NAME (Laaet-F iva t-Aiddia) 2. RELATIONSHIP Flores 6 Brother 4, CURRENT ‘a., Street, City, Zone, State, Country) Deceased nn. % 3. CITIZENSHIP (Country) U.S. of America & LIVING 6 AGE | ves nO 3. CITIZENSHIP (Camétry) U.S. of America &. LIVING & AGE YES NG 39 3. CITIZENSHIP (Country) U.S. of America &. LIvViIng 6. AGE YES NO 3 3. CITIZENSHIP (Country) U.S. of America 8. LIVING 6. AGE XK | ves NO 2 3. CITIZENSHIP (Country) U.S. of America 8. LIVING 6. AGE X | ves NO e 3. CITIZENSHIP (Country) U.S. of America S Living 6. AGE K | ves NO 2 3. CITIZENSHIP (Coumery) U.S. of America 8. LIVING 6. AGE YES NO 7 3. CITIZENSHIP (Coumtry) U.S. of America S&S. LIVING & AGE YES wo | NA
SECTIONXVH FATHER-IN-LAW 7. EULL NAME (Last-Firet-Middle) Ob 3. DATE OF DEATH | 4. CAUSE OF DEATH 8. STATE OTHER NAM ai u 6 INDICATE CIRCUMSTANCES (Including length of time) UNDER WHICH HE HAS EVER USEO THESE NAMES. IF LEGAL CHANGE, GIVE PARTICULARS (Where and by what authority). USE EXTRA SPACE PROVIDED ON PAGE 16 OF THIS Ray FORM TO RECORD THIS INFORMATION. 6. CURRENT OR LAST ADDRESS (No., Street, City, State, Country) 2) ys | |Yregon “7 DATE OF BIRTH ate, Country) oe CITIZENSHIP ‘January 2, 1909 - kota U.S. of america 10, IF BORN OUTSIDE U.S.- DATE OF ENTRY 11. PLACE OF ENTRY NA 12. FORMER CITIZENSHIP(S) fCountry(iea)/ 13. DATE U.S. CITIZENSHIP WA : ACQUIRED WA 18. OCCUPATION . | Warehouse Foreman SECTION XVI. On MOTHER-IN-LAW T. FULL NAME (Last-First-Middle) % 3. DATE OF DEATH | 4. CAUSE OF DEATH il a x Tves | [xe | 3 “STATE OTHER NAMES SHE HAS USED INDICATE CIRCUMSTANCES (Including length of time} UNDER WHICM SHE HAS EVER USED THESE NAMES. IF LEGAL CHANGE, GIVE PARTICULARS (Where Q and by what authority}, USE EXTRA SPACE PROVIDED ON PAGE 16 OF THIS 1 . 23 FORM TO RECORD THIS INFORMATION. RRENT OR LAST ADDRESS (No., Street, City, State, Country) ye Oregon : 7, OATE OF BIRTH May 1910 . 10. IF BORN GUTSIDE U.S. °- DATE OF ENTRY 8. PLACE OF BIRTH Portiand, Oreg at. PLACE OF EN 14, WHERE ACQUIRED (City, State, Country) Na PRESENT EMPLOYER (Give last employer, if Motherin-Lew is deceased or memployed) «3. DATE U.S. CITIZENSHIP ACQUIRED WA 12. FORMER CITIZENSHIP(S) LCountry{iesz7 WA .: “RELATIVES BY BLOOD, MARRIAGE OR ADOPTION WHO EITHER (1) LIVE ABROAD, (2) ARE NOT U.S. CITIZENS OR (3) WORK FOR A FOREIGN GOVERNMENT a 8. EMPLOYED BY 8. DATE OF LAST CONTACT : 2. RELATIONSHIP pense 5. EMPLOYED BY 8. DATE OF LAST CONTACT &, ADDRESS OR COUNTRY IN WHICH RELATIVE RESIDES 5. EMPLOVED BY ) : 6. CITIZENSHIP (Country) 7. FREQUENCY OF CONTACT 8. DATE OF LAST CONTACT ° ° ‘ SECTION XIX CONTINUED TO PAGE 13 . . . a eememcemmmees we ON ee canna ttre cna eas a Oo FULL NAME (Last-Pirat-Middie) None to my. knowledge 4. ADDRESS OR COUNTRY IN WHICH RELATIVE RESIDES 4. ADDRESS OR COUNTRY IN WHICH RELATIVE RESIDES 6. CITIZENSHIP (Country) 7. FREQUENCY OF CONTACT 1, FULL NAME (Laat-First-Middie} & ADDRESS OR COUNTRY IN WHICH “ELATIVE RESIDES 6. CITIZENSHIP (Coumiry) 7. FREQUENCY OF CONTACT FULL NAME (Laat-F irsi-Middie) . Gl
14-00000 tate ‘ ® . * _ — _esuaaesaen ena stenoses ssrB, SPCP REDEEM rest Oeste SAM eet 590 SESE SET TTT SCT TTT, + [SECTION XXIV . ADDITIONAL INFORMATION * * 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 BEEN 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? iF YOU HAVE ANSWERED “YES* TO THE ABOVE QUESTION, EXPLAIN | [ves | 4.1F $0, TO WHAT EXTENT? 3. DO YOU USE OR HAVE You EVER USED INTOXICANTS? iX[xo | 6. IF SO, TO WHA NT? 5. DO YOU USE OR HAVE You ives | T EXTENT EVER USED NARCOTICS? Xlxo | 7. HAVE YOU EVER BEEN A MEMBER OF, OR SUPPORTED, OR HAD ANY CONNECTIONS WITH A FOREIGN INTELLIGENCE ORGAN- IZATION OR ITS ACTIVITIES? Clves [x]no IF ANSWER IS "VES", GIVE COMPLETE DETAILS. 8. LIST BELOW THE NAMES OF GOVERNMENT DEPARTMENTS, AGENCIES OR OFFICES TO WHICH YOU HAVE APPLIED FOR EM- PLOYMENT SINCE 1940 I served | years in the United States Marine Corps. Lo KNOWLEDGE, ANY OF THE ABOVE HAVE CONDUCTED AN INVESTIGATION OF YOU, INDICATE THE NAME OF THE D THE APPROXIMATE DATE OF THE INVESTIGATION. An investigation ( I do not know by whom) was conducted prior to my departure for Bolivia where I was attached to the American or 1988. This investigation took place during August and September of 19 e NOTE SPECIAL INSTRUCTIONS 10. HAVE YOU, OR TO YOUR KNOWLEDGE HAS YOUR SPOUSE, EVER BEEN DETAINED, ARRESTED, INDICTED OR CON- vicTep EGR ANY VIOLATION OF THE LAW OTHER THAN A MINOR TRAFFIC VIOLATION IN THE UNITED STATES OR lf $0, 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 BEEN ARRESTED, COURT-MARTIALED OR OTHERWISE PUNISHED UNDER MILITARY LAW OR REG- ULATION? fF SO, DESCRIBE INCIDENTIS) AMD PROVIDE DATE(S) OF OCCURRENCE ON SEPARATE SHEET IN AC- CORDANCE WITH SPECIAL INSTRUCTIONS ABOVE. RE ANY UNFAVORABLE INCIDENTS IN YOUR LIFE, NOT MENTIONED ABOVE, WHICH MAY BE OISCOVERED QUENT INVESTIGATION, WHETHER YOU WERE DIRECTLY INVOLVED OR NOT, WHICH MIGHT REQUIRE EX- ON? IF $0, DESCRIBE INCIDENTIS) AND PROVIDE DATE(S) OF OCCURRENCE ON SEPARATE SHEET IN AC- CE WITH SPECIAL INSTRUCTIONS ABOVE. e PERSON TO BE NOTIFIED IN CASE OF EMERGENCY 1. NAME (Firat-Middle-Last) 2. RELATIONSHIP Mrs. Daniel Flores Wife 4. HOME PHONE NO. é Washington 6, D.C, 7.1N CASE OF EMERGENCY, OTHER CLOSE RELATIVES (Spouse, Mother, Father) MAY ALSO BE NOTIFIED. {Ff SUCH NOTIFICATION iS NOT DESIRABLE, BECAUSE OF HEALTH OR OTHER REASONS, PLEASE SO STATE. 0 In all cases wife: Relative, Mrs. o& tol | Texas Telephone ID - 18 - oF
14-00000 ~ see ®, | SECTION XXVI CERTIFICATION YOU ARE INFORMED THAT THE CORRECTNESS OF ANY STATEMENT MADE WILL BE INVESTIGATED. IN THIS APPLICATION jf have read and understand the instructions. i Certify thet the foregoing answers ore true and correct te the best of m knowledge and belief. {| agree thot any misstatement or omission a3 fo material fact will constitute grounds for immediate dismissal or rejection-of m application. t alse understand that any false statement made herein may be punishable by law (U.S. Cede, Tithe 18, Section 1007). NOTE: Use the following space for extra details. Reference each continued item by sectionfind item number to which it relates, sign your name at the end of the added material. If additional space is required usd extra pages the same size as this page and sign each such page. ‘ MARITAL STATUS: Item #4, Section XII . o& September 1, 1956 to October 6, 1956. Married to in Portland, Oregon, by Circuit Court Judge. Used name of; un November 1), 1960, when changed to Flores. a FATHER-IN-LAW: Item #5, Section XVII Short name for Raymond GEOGRAPHIC AREA KNOWLEDGE AND FOREIGN TRAVEL: Item #1, Section VI Argentina 2 July 1959 to 3 July 1959 Travel Panama . 10 November 1958 to 13 November 1958 Travel - SEE ATTACHED SHEET FOR PERTINENT INFORMATION RELATIVE TO STEP-MOTHER. Signed at Washington, D. C., this {= aay of September, Daniel Flores
14-00000 tout > et? on or ey ATTACHMENT TO FORM NO. bil - PERSONAL HISTORY STATEMENT Section XV - STEPMOTH=R Full name: | Flores Living: Yes Other Names She s Used: None to my knowledge Current. heaves: (fn tenes Date of Birth: December 8, 191h oO Place of Birth: Mexico Citizenship: Mexican If Born Outside U.S. - Date of Entry: December 8, 1922 Place of Entry: Unknown Former Citizenships: None Occupation: Homemaker and Missionary 08 Present Employer: } Texas Never served in Milftary or other Government service to my knowledge. This paper is attached to and hereby made a part of Form No. \hh. CS