-14- e@ [SECTION xxi 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 or have belonged. ; a ; . ADDRESS | DATES OF MEMBERSHIP NAME AND CHAPTER (Number, Street, City, State, Country) Airborne Association Ft. Bragg, North Washington, D.C. Washington, D.C. e ADDRESS - LAST RESIDENCE FIRST (Number, Street, City, State, Country) “~ 13 Maas Drive, Ft. Bragg No 5 Kuchi Safa, Teheran, Iran (Mil Idaison Gp bom —~ cr enenenens i f . - a Pe mre te vey es : ee ee wo. to -- _ HW 53294 Bocld:323992765 Page 15 a et
e . oa . . . . . f mae) : . oe nnn ba or = — - - SECTION XXIV . aaa ADDITIONAL INFORMATION soos t. DO YOU ADVOCATE OR HAVE YOU EVER ADVOCATED; OR ARE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF; Yes 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 x THEIR RIGHTS UNDER THE CONSTITUTION OF THE UNITED STATES? 2. 1F YOU HAVE ANSWERED “YES” TO THE ABOVE QUESTION, EXPLAIN 3. DO YOU USE OR HAVE YOU EVER USED INTOXICANTS? . DO YOU USE OR HAVE YOU EVER USED NARCOTICS? Ix|no “HAVE YOU EVER BEEN A MEMBER OF, OR SUPPORTED, OR HAD ANY CONNECTIONS WITH A FOREIGN INTELLIGENCE ORGAN- IZATION OR ITS ACTIVITIES? & Yes (_]nNo IF ANSWER IS *YES", GIVE COMPLETE DETAILS. © Wilitary Liaison to J~2 SCS, Imp Iranian Army 1959 to 1961 ~ LIST BELOW THE NAMES OF GOVERNMENT DEPARTMENTS, AGENCIES OR OFFICES TO WHICH YOU HAVE APPLIED FOR EM- PLOYMENT SINCE 1940 UeSe Army LEDGE, ANY OF THE ABOVE HAVE CONDUCTED AN INVESTIGATION OF YOU, INDICATE THE NAME OF THE APPROXIMATE DATE OF THE INVESTIGATION. : OSS 193 U.S. Army 1956-57 SsU 196 ACSI D of A 1959 GIG 1947 CIA 1948-9 to the following Questions 10, 11 or 12, provide the information requested for each d sheet and attach the sheet to this form in a sealed envelope. If your answer is “YES” question on o separate, signe NOTE SPECIAL INSTRUCTIONS | 10. HAVE YOU, OR TO YOUR KNOWLEDGE HAS YOUR SPOUSE, EVER BEEN DETAINED, ARRESTED, IND! VICTED ROR ANY VIOLATION OF THE LAW OTHER THAN A MINOR TRAFFIC VIOLATION IN THE UNIT IF SO, STATE NAME OF COURT, CITY, STATE, COUNTRY, DATE, NATURE OF OFFENSE AND DISPOSITION OF CASE IN ACCORDANCE WITH THE SPECIAL INSTRUCTION ABOVE. . ED OR CON- CT ED STATES OR it. VE YOU EVER BEEN ARRESTED, ok T-MARTIALED OR OTHERWISE PUNISHED UNDER MILITARY LAW OR REG- HA COUR l HANEION? If $0, DESCRIBE INCIDENT(S) AND PROVIDE DATE(S) OF OCCURRENCE ON SEPARATE SHEET IN AC" CORDANCE WITH SPECIAL INSTRUCTIONS ABOVE. 12. ARE THERE ANY UNFAVORABLE INCIDENTS IN YOUR LIFE, NOT MENTIONED ABOVE, WHICH MAY BE DISCOVERED IN SUBSEQUENT INVESTIGATION, WHETHER YOU WERE DIRECTLY INVOLVED OR NOT, WHICH MIGHT REQUIRE EX- PLANATION? IF SO, DESCRIBE INCIDENT(S) ANO PROVIDE DATE(S) OF OCCURRENCE ON SEPARATE SHEET IN AC- CORDANCE WITH SPECIAL INSTRUCTIONS ABOVE. Y 2. RELATIONSHIP SECTION XXV PER 1. NAME (First-Middle-Last) Elyette Brochot Conein 3. HOME ADBRESS (No., Street, City, Zone, State, Country) 5 BUSINESS ADDRESS (No., Street, City,. Zone, State, Country) - INDICATE NAME OF FIRM OR|6. BUSINESS PHONE NO. & EXT. EMPLOYER, IF APPLICABLE Dept of the Army N CASE OF EMERGENCY, OTHER CLOSE RELATIVES (Spouse, Mother, Father) MAY ALSO BE NOTIFIED. IF SUCH NOTIFICATION S NOT DESIRABLE, BECAUSE OF HEALTH OR OTHER REASONS, PLEASE SO STATE. . SON TO BE NOTIFIED IN CASE OF EMERGENC 4. HOME PHONE NO. OX 57742 7.1 t lirs, Estelle Conein. 150 Monterey St. Brisbane.Calif. Mother -15- HW 53294 Bocld:323992765 Page 16 es eee menage ones
"Li6- af ee . @ |SECTICg! %XVd . CERTIFICATION e © YOU ARE INFORMED THAT THE CORRECTNESS OF ANY STATEMENT MADE IN THIS APPLICATION . WILL BE INVESTIGATED. | have read and understand the instructions. | Certify that the foregoing answers are true and correct to the best of my knowledge and belief. | agree that any misstotement or omission as to material fact will constitute grounds for immediate dismissal or rejection of my application. {also understand that any false statement made herein may be punishable by law (U.S. Code, Title 18, Section 1007). : a . 1. DATE OF SIGNATURES 26. leg Mert ity SG ES 13. SIGNEDO AT (City and State) 4. SIGNATURE OF WITNESS + i if ~~ NOTE: Use the following space for extra details. Reference each continued item by section and item hbnbes to which it relates, sign your name at the end of the added material. If additional space is required use extra pages the same size as this 2. SIGNATURE OF APPLICANT ‘ page and sign each such page. ee ce neta ne atin RRA net Sete anes cee at tune een natpinnnnennneremneemath i mtn amme earhnes = oe i ' f ‘ t oo. i 1 ‘ } 2 \ t , ' ' i H , t ‘ ' i i ; ‘ 1 i 4 } 1 L | 4 i i i { - , i i t - ° NEE ee a nementl ERE . \ ~* . x ied . . sey mo ee gt amet . a . . oot a cesta tone wen nto any sable whee MS peasp enema eneria wn eumn enbtedion Goreme enim cxiee Ee! repent Toes ac anes hema EE ements ss Rennteam t ENR gow HW 53294 DBocld:323992765 Page 17