FORM:PERSONAL HISTORY STATEMENT OF CONEIN, LUCIEN EMILE
Agency: CIA
Originator: CIA
To: CONEIN, LUCIEN
Document date: 09/25/1961
Document type: PAPER - TEXTUAL DOCUMENT

## Page 1

Date: 01/26/05

JEK ASSASSINATION SYSTEM

IDENTIFICATION FORM

AGENCY INFORMATION

AGENCY : CIA

RECORD NUMBER: 104-10112-10093

RECORD SERIES : JEK

AGENCY FILE

NUMBER

80T01357A

Released under the John

F. Kennedy

Assassination Records

Collection Act of 1992

144 USC 2107 Notel.

Case#:NW 53294 Date:

76-14-2017

DOCUMENT INFORMATION

AGENCY ORIGINATOR : CIA

FROM : CONEIN, LUCIEN

TO :

TITLE : FORM: PERSONAL HISTORY STATEMENT OF CONEIN, LUCIEN EMILE

DATE: 09/25/1961

PAGES : 16

SUBJECTS : CONEIN, LUCIEN

DOCUMENT TYPE

: PAPER

: UNCLASSIFIED

RESTRICTIONS : 1A

CURRENT STATUS : RELEASED IN PART PUBLIC - RELEASED WITH DELETIONS

DATE OF LAST REVIEW

: 07/22193

COMMENTS

JFK41: F2: 1993.07.22.18:47:22:590390

IRI - ITEM IS RESTRICTED

104-10112-10093

HH 53294

DocId: 32399265

Page 1

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THIS DATE (Fill in)

•DO NOT USE THIS SPACE,

ISEUED BY

PERSONAL HISTORY STATEMENT

25 September 1961

INSTRUCTIONS

SECTION I

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.

GENERAL PERSONAL AND PHYSICAL DATA

2. AGE

3. SEX

1. FULL NAME (Last-First-Middle)

CONTIN,

Lucien Emile

4. HEIGHT

15. WEIGHT

6. COLOR OF EYES

5'11"

1751b5

blue

Llyrs

X MALE

7. COLOR OF HAIR

8. TYPE COMPLEXION

brown

fair

FEMALE

9. TYPE BUILD

medium

10. SCARS (Type and Location):

appendectomy, hernia, st. side of body

11. OTHER DISTINGUSHING PHYSICAL FEATURES

first jointr it. index and middle finger amputated

12. CURRENT ADDRESS (No., Street, City, Zore, State and Country)

13. PERMANENT ADDRESS (No., Street, City, Zone, State and

Country) AND PHONE NO.

5011 Hanes Street

McLean, Virginia

1905 North lOth Street

Elmwood 6-4811

Kansas City, Kansas

14. CURRENT PHONE NO.

ELmwood 6-4811

15. OFFICE PHONE NO. & EXT.

OXford 57742

16. LEGAL RESIDENCE (State, Territory or Country)

Kansas

18. OTHER NAMES YOU HAVE USED

17. NICKNAMES

Luigi

19. INDICATE CIRCUMSTANCES (Including Length of Time) UNDER WHICH YOU HAVE EVER USED THESE NAMES.

20. IF LEGAL CHANGE, GIVE PARTICULARS (Where and by What Authority).

NA

POSITION DATA

SECTION II

1. INDICATE THE TYPE OF WORK OR POSITION FOR WHICH YOU ARE APPLYING.

Position comensurate with past training and experience

2. INDICATE THE LOWEST

entrance salary).

13. DATE AVAILABLE FOR EMPLOYMENT

$ 11.500. 00 x2

1 October 1961

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.

CERTAIN LOCATIONS ONLY (Specily):

OUTSIDE CONTINENTAL U.S.

6. INDICATE WHAT RESERVATIONS YOU WOULD PLACE ON ASSIGNMENTS OUTSIDE THE WASHINGTON, D.C. AREA.

NONE

....:

FORM 444 USE PREVIOUS EDITION.

11-58

- 1.

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• 2.

SECTION III.

CITIZENSHIP

1. DATE OF

BIRTH

2. PLACE OF BIRTH (City, State, Gouniry)

3. PRESENT CITIZENSHIP (Country)

29 Now 1919

Paris, France

4. CITIZENSHIP ACQUIRED BY

5. PALE NATURAL-

6. NATURSLIZATION CERTIFICATE NO.

BIRTH

MARRIAGE

X OTHER (Speckly):

11 August 142

5426522

7. COURT ISSUING NATURALIZATION CERTIFICATE

ISSUED AT (City, Stato, Country)

District Court

Tacona, Washington

9. HAVE YOU HELD PREVIOUS NATIONALITY

10. IF YES, GIVE NAME OF COUNTRY

11. GIVE PARTICULARS

CONCERNING PREVIOUS NATIONARICe, (see above)

Born France 1919, emigrated U.S. 1925.

12. HAVE YOU TAKEN STEPS TO CHANGE

YES

13. GIVE PARTICULARS

PRESENT CITIZENSHIP

NA

14. IF YOU HAVE APPLIED FOR U.S. CITIZENSHIP, WHAT IS PRESENT STATUS OF YOUR APPLICATION (First Papero, Etc.)?

NA

15. DATE OF ARRIVAL IN U.S.

16. PORT OF ENTRY

Sept 1925

New York City, New York

18. LAST U.S. VISA (No., Type, Place of Issue)

unknown

17. ON PASSPORT OF WHAT COUNTRY

France

19. DATE VISA ISSUED

unknown

SECTION IV

LESS THAN HIGH SCHOOL GRADUATE

HIGH SCHOOL GRADUATE

TRADE, BUSINESS, OR COMMERCIAL SCHOOL GRADUATE

TWO YEARS COLLEGE OR LESS

1. NAME OF ELEMENTARY SCHOOL

Abbott Grade School

3. DATES ATTENDED (From-and-To)

1926 to 1932

EDUCATION

1. CHECK (X) HIGHEST LEVEL OF EDUCATION ATTAINED

OVER TWO YEARS OF COLLEGE. NO DEGREE

BACHELOR'S DEGREE

GRADUATE STUDY LEADING TO HIGHER DEGREE

MASTER'S DEGREE

DOCTOR'S DEGREE

2. ELEMENTARY SCHOOL

2. ADDRESS (City, State, Country)

Kansas City, Kansas

A. GRADUATE

YES

NO

1. NAME OF HIGH SCHOOL.

Wyandotte High

3. DATES ATTENDED (From-and-To)

1932 to 1934

1. NAME OF HIGH SCHOOL

3. HIGH SCHOOL

2. ADDRESS (City, Stato, Country)

Kansas City, Kansas

A: GRADUATE

YES

2. ADDRESS (City, State, Country)

XI NO

3. DATES ATTENDED (From-and To) .

4. GRADUATE

NAME AND LOCATION OF COLLEGE OR UNIVERSITY

University of Maryland

YES

A. COLLEGE OR UNIVERSITY STUDY

SUBJECT

DATES ATTENDED

MAJOR MINOR

FROM

Mil

Se

1949

1953

NO

DEGREE

REC'D

ATI

EC''

SECTION IV CONTINUED TO PAGE 3

SEM/QTR

HOURS

(Specify)

77

*.....

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SECTION IV CONTINUED FROM PAGE 2

5: IF AGE AUSTS DE BRIEFEY DESCRIBE EPS CONTEN WHICH REQUIRED SUBMISSION OF A MRITTEN THESIS, INDICATE THE TITLE

NA

NAME AND ADDRESS OF SCHOOL

6. TRADE, COMMERCIAL AND SPECIALIZED SCHOOLS

STUDY OR SPECIALIZATION

FROM

TO

MONTHS

NA

7. MILITARY TRAINING (FULL TIME DUTY IN SPECIALIZED SCHOOLS SUCH AS ORDNANCE, INTELLIGENCE, COMMUNICATIONS, ETC.)

NAME AND ADDRESS OF SCHOOL

STUDY OR SPECIALIZATION

FROM

TO

MONTHS

OGS, TIS, Ft Benning, Ga.

OCS

MAR 43

July 43

4

Special WarfareFt Bragg

Special Forces

Nov 1956

Dec 1956

8. OTHER EDUCATIONAL_TRAINING NOT INDICATED ABOVE.

OSS and Agency Schools

SECTION V

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).

French

EQUIV-

'ALENT

TO

NATIVE

FLUENCY

R

W

FOREIGN LANGUAGE ABILITIES

COMPETENCE - IN ORDER LISTED

R-Read,

W-Write,

S-Speak

FLUENT

BUT

OBVIOUSLY

FOREIGN

ADEQUATE ADEQUATE

RESEARCH

TRAVEL

R

W

5

R

LIMITED

KNOW-

LEDGE

W

NATIVE

OF

COUNTRY

HOW ACQUIRED

PRO

CONTACT ACADEMIC

LONGED

(with

STUDY

RES

parents,

(all

IDENCE

etc.)

levels)

2. IF YOU HAVE CHECKED "ACADEMIC STUDY" UNDER "HOW ACQUIRED®, INDICATE LENGTH AND INTENSIVENESS OF STUDY.

NA

'OU HAVE INDICATEL

FLUENCY FOR A LANGUAGE HAVING SIGNIFICANT DIFFERENCES IN SPOKEN AND WRITTEN. FORM, EX-

3. PLAN YOUR COMPETENCE THEREIN

NA

4. DESCRIBE YOUR ABILITY

TIFIC, ENGINEERING,

TELECOMMUNICATIONS, MILITARY, AND OTHER SPECIALIZED WARDES AND TERMINOLOGY IN THE SCIEN

OTHER SPECIALIZED FIELDS.

none

5. IF

YOU MIGHT BE SELECTED?

ESTEECT EROFICIENCY IN LANGUAGE, WOULD YOU BE WILLING TO USE THIS ABILITY IN ANY POSITION FOR WHICH

-3 .

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•4 .

SECTION VI

GEOGRAPHIC AREA KNOWLEDGE AND FOREIGN TRAVEL

ROADS, INDUSTRIES, POLITICAL PARTIES, ETC.

REGION OR COUNTRY

SPECIALiZED KNOWLEDGE

DATES OF

RESIDENCE

OR TRAVEL

JATES AND

PLACE OF STUDI

BENCE

KNOWLEDGE ACQUIRED BY

WORK

TRAVEL STUDY ASSIGN

MENT

france

China

military

1944

OSS

military

1945

OSS

Indochina

military-polit

Cermany

intelligence

1945856-59

1946-1953

OSS

SSU

CIA

intelligence

1959 - 1961

2. INDICATE THE PURPOSE OF VISIT, RESIDENCE, OR TRAVEL IN EACH OF THE REGIONS OR COUNTRIES LISTED ABOVE.

ACSI

Military assigments

3. UNITED STATES PASSPORT NUMBER AND EXPIRATION DATE, IF ISSUED.

SP 207111. 27 July 1959 exp 27 July 1963

TYPING AND STENOGRAPHIC SKILLS

SECTION VI!

1. TYPING (wpm)

2. SHORTHAND (wpm)

3. SHORTHAND SYSTEM USED - CHECK (X) APPROPRIATE ITEM

SPEEDWRITING

STENOTYPE OTHER (Specify):

2. INDICATE OTHER BUSINESS MACHINES WITH WHICH YOU HAVE HAD OPERATING EXPERIENCE OR

TRAINING (Comptometer,

Mimeograph, Card Punch, Etc.).

NA

SECTION VIII

SPECIAL QUALIFICATIONS

". IN EACH. HOBBIES AND SPORTS IN WHICH YOU ARE ACTIVE OR HAVE ACTIVELY PARTICIPATED. INDICATE YOUR PROFICIENCY

Hunting - Good

Fishing - Goog

Free Fall Parachuting - Good

2. INDICATE ANY SPECIAL

QUALIFICATIONS. RESULTING FROM EXPERIENCE OR TRAINING WHICH MIGHT FIT YOU FOR A

PARTICULAR POSITION OR TYPE OF WORK.

OSS and Agency trained

Special Forces Battalion Conmander 3yrs

Chief Military Liaison Group, ACSI intel (FI) team Teheran Iran

POSSESS RELATING

cate CW speed, sending and receiving), OFFSET PRESS, TURRET LATHE, SCIENTIFIC AND PROFESSIONAL DEVICES.

none

SECTION VIII CONTINUED TO PAGE 5

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SECTION VIII CONTINUED FROM PAGE 4

ARE YOU NOW OR HAVE YOU EVER

LECTRICIAN, RADIO OPERATOR,

TEACHER CENTER, EP A MEDIER EEEEN, ETERADE OR PROFESSION, SUCH AS PILOT,

DrES

ENO

5. IF YOU HAVE ANSWERED "YES" TO ABOVE, INDICATE KIND OF LICENSE AND STATE ISSUING LICENSE (Provide License Registry

6. FIRST LICENSE OR CERMFICATE (Year of Issue)

7. LATEST LICENSE OR CERTIFICATE (Year of Issue)

8. LIST

THE

ANYE, PUELICATION DATE, ANA TYPE OF WAITING (NE Scientilic articles,

PUBLICATION DATE,

on or Scientitic articles, Gone Inpies to red Cared, DICATE

Stories, Etc.).

9. INDICATE ANY DEVICES WHICH YOU HAVE INVENTED A

NO STATE WHETHER OR NOT THEY ARE PATENTED.

10. LIST PUBLIC SPEAKING AND PUBLIC RELATIONS EXPERIENCE.

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.

SECTION IX

EMPLOYMENT HISTORY

NOTE: (LIST LAST POSITION FIRST.) Indicate chronological 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 periods of

unemployment. List all civilian employment by a foreign Govemment, regardless of dates. In completing item 9,

"Do -

scription of Duties® consider your experience carefully and provide meaningful, objective statements.

T. INCLUSIVE DATES (From and To - By Mo. and Yr.)

2. NAME OF EMPLOYING FIRM OR AGENCY

U.S. Army Sept 1941 to pres.

U.S. Army

3. ADDRESS (No., Street, City, State, Country)

Washington 25 D.C.

4. KIND OF BUSINESS

Military

6.

TITLE OF JOB

Lt. Colonel

9. DESCRIPTION OF DUTIES

5. NAME OF SUPERVISOR

M/Gen John Willems

7. SALARY OR EARNINGS

$11,561 16PER year

8. CLASS. GRADE(I Federal Service)

Ito Col.

U.S. Army Officer assigned to the Assistant Ghief of Staff for Intelligence

10. REASONS FOR LEAVING

am retiring after 2uyrs 3mos I days service

SECTION IX CONTINUED TO PAGE 6

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1. INCLUSIVE DATES (From and To - By Mo. and Yr.)

SECTION IX CONTINUED FROM PAGE 5

2. NAME OF EMPLOYING FIRM OR AGENCY

3. ADDRESS (No., Street, City, State, Country)

4. KIND OF BUSINESS

6. TITLE OF JOB

9. DESCRIPTION OF DUTIES

5. NAME OF SUPERVISOR

7. SALARY OR EARNINGS

PER

I8. CLASS. GRADE (Il Federal Servico)

10. REASONS FOR LEAVING

1. INCLUSIVE DATES (From and To - By Mo. and Yr.)

3. ADDRESS (No., Street, City, State, Country)

4. KIND OF BUSINESS

6. TITLE OF JOB

9. DESCRIPTION OF DUTIES

2. NAME OF EMPLOYING FIRM OR AGENCY

5. NAME OF SUPERVISOR

$

7. SALARY OR EARNINGS

PER

8. CLASS, GRADE (I{ Federal Service)

10. REASONS FOR LEAVING

1. INCLUSIVE DATES (From and To - By Mo. and Yr.)

3. ADDRESS (No., Street, City, State, Country)

4. KIND OF BUSINESS

6. TITLE OF JOB

9. DESCRIPTION OF DUTIES

2. NAME OF EMPLOYING FIRM OR AGENCY

5. NAME OF SUPERVISOR

7. SALARY OR EARNINGS

PER

18. CLASS. GRADE (Il Federal Service)

10. REASONS FOR LEAVING

1. INCLUSIVE DATES (From and To - By Mo. and Yr.)

3. ADDRESS (No.,, Streel, City, State, Country)

4. KIND OF BUSINESS

6, TITLE OF JOB

2. NAME OF EMPLOYING FIRM OR AGENCY

5. NAME OF SUPERVISOR

$

7. SALARY OR EARNINGS

PER

SECTION IX CONTINUED TO PAGE 7

8. CLASS. GRADE (Il Federal Service)

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SECTION IX CONTINUED FROM PAGE 6

DESCRIPTION OF DUTIES

5

10. REASONS

FOR LEAVING

1. INCLUSIVE DATES (From and To - By Mo. and Yr.)

3. ADDRESS (No.,, Street, City

State, Country) -

4. KIND OF BUSINESS

6. TITLE OF JOB

9. DESCRIPTION OF DUTIES

2. NAME OF EMPLOYING FIRM OR AGENCY

5. NAME OF SUPERVISOR

I$

7. SALARY OR EARNINGS

PER

• 8. CLASS. GRADE (If Federal

Service)

10. REASONS FOR LEAVING

1. INCLUSIVE DATES (From and To - By Mo. and Yr.)

3 ADDRESS (No., Street, City, State, Country)

4. KIND OF BUSINESS

2. NAME OF EMPLOYING FIRM OR AGENCY

5. NAME OF SUPERVISOR

6. TITLE OF JOB

9. DESCRIPTION OF DUTIES

7. SALARY OR EARNINGS

PER

8.

CLASS. GRADE (If Federal

Sernice)

10. REASONS FOR LEAVING

8. IF PRIOR

SERVICE WITH

NUMBER OF

VIES CREDTABLE TOWA

TOWARD U.S

RO YER CEN SERVICE RETIREMENT.

NDICATE In

9. HAVE YOU EVER BEEN UISCHARGED OR ASKED TO RESIGN FROM ANY POSITION.

HAVE YOU LEFT A POSITION UNDER CIRCUMSTANCES WHICH YOU DESIRE TO EXPLAIN?

IF YOUR ANSWER TO EITHER OR BOTH QUESTIONS IS "YES", GIVE DETAILS

YES

REINO

DYES DINO

:?...

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SECTION X:

MILITARY SERVICE

1. CURRENT DRAFT STATUS

1. ARE YOU RÉGISTERED FOR THE DRAFT

UNDER

THE

UNIVERSAL

MILITARY

TRAINING AND

2. SATECTIVE SERVICE CLASSIFI

3. SELECTIVE SERVICE NO.:

SERVICE ACT

OF 1948 (As amended)

NO

4. IF DEFERRED, GIVE REASON

5. LOCAL DRAFT BOARD NO. OR DESIGNATION AND ADDRESS

USAR Ret Reserves

CHECK (X) AS

APPROPRIATE

ARMY

NAVY

NA

2. MILITARY SERVICE RECORD

1. CURRENT AND/OR PAST ORGANIZATIONAL MEMBERSHIP

MARINE

CORPS

AIR

FORCE

COAST

MERCHANT

NATIONAL AIR NAT'L

GUARD

MARINE

GUARD

GUARD

FOREIGN

ORGAN.

OR MIL.

SERVICE (Specily):;

HAVE SERVED+

NOW SERVING

2. BRANCH OR CORPS OF ABOVE CHECKED ORGANIZATION(S)

paractube infantry

3. DATE SEPARATED FROM EXTENDED ACTIVE DUTY (Past service)

LENGTH OF EXTENDED ACTIVE DUTY IN U.S. ARMED

NA

5. DATE ENTERED

ACTIVE

DUTY

PAST SERVICE

22 Sept 41

7. RANK, GRADE OR

PAST SERVICE

prite

9. PRIMARY MILITARY OCCUPATIONAL

SPECIALTY (Mos or Designator) AND TITLE

CURRENT SERVICE

NA

CURRENT SERVICE

Its

PAST

SERVICE

6. TOTAL

TONALAT ONGTH OF ACTIVE DUTY IN FOREIGN MILITARY OR

18mos

8. SERVICE SERIAL OR FILE NUMBER (Il now serving, provide cur

01-32210

CURRENT SERVICI

11542

PAST SERVICE

URRENT SERVIC

10. SECONDARY

MIL.

OCCUPATIONAL

SPECIALTY (Mos or Designator) AND

11. BRIEF DESCRIPTION OF MILITARY DUTIES (indicate whether applicable to past or current cer 300300

Ch ief of Military Liaison Group, ARMISH/MAAG, APO 205 NY, NY

12. CHECK (X) TYPE OF SEPARATION FROM ACTIVE DUTY

HONORABLE DISCHARGE:

RELEASE TO INACTIVE DUTY

RETIREMENT FOR AGE

RETIREMENT FOR SERVICE

RETIREMENT FOR COMBAT DISABILITY

UNDUE HARDSHIPS

OTHER:

NA

RETIREMENT FOR PHYSICAL DISABILITY

13. CHECK (X) COMPONENT IN WHICH YOU SERVED

REGULAR

RESERVE (Including the National and Air National Guard)

3. MILITARY RESERVE, NATIONAL GUARD AND ROTE STATUS

1. DO

YOU NOW HAVE X

RESERVE STATUS?

YES

2. ARE

YOU NOW

NAT'L. GRD. OR

OR AIR NAT'L

OF THE

YES

NO

OTHER (Including AUS)

AUS

3.

ARE YOU NOW A MEMBER O

•HE ROTC!

NO

GRD.?

YES

NO

4. IF YOU HÄVE ANSWERED "YES" TO ITEMS 1, 2 OR 3 ABOVE, CHECK COMPONENT MEMBERSHIP BELOW

X ARMY

MARINE CORPS

NATIONAL GUARD

COAST GUARD

NAVY ROTC

INDICATE ROTE CATEGORY NUM

NAVY

AIR FORCE

AIR NAT'L. GUARD

ARMY ROTC

AIR FORCE ROTC

BER

5. CURRENT RANK, GRADE OR

RATE

It Col

RANE OF B JULY 58 IN CURRENT

7. EXPIRATION DATE OF CURRENT RESERVE OBLIGA-

• 1 Oct 1961

8. CHECK (X) CURRENT RESERVE CATEGORY

READY RESERVE

STANDBY(Active)

[STANDBY (Inactive) & RETIRED

9. PRIMARY MILITARY OCCUPATIONAL SPECIALTY (Mos or Denig-

SECONDARY MILITARY OCCUPATIONAL SPECIALTY (MOs Or Des-

nator) AND TITLE

NA

ignator) AND TITLE

NA

11. BRIEF DESCRIPTION OF MILITARY RESERVE DUTIES

NA

2. ARE YOU CURRENTLY ASSIGNED OR ATTACHE

•OÀ RESERVE, NAT'L. GUARD OR ROTC TRAI

ING UNIT

14. HAVE

MENT YOU A MILITARY MOBILIZATION ASSIGN-

16. INDICATE TOTAL MILITARY SERVICE

YEARS

FOR

LONGEVITY PURPOSES INCLUD-

ING ACTIVE

AND INACTIVE

DUTY

2h

YES

NO

YES

NO

MONTHS

3

13. AND AUDRYESANSWERED "YES" TO ITEM 12, GIVE UNIT OR AGENCY

15. AND ADDRESS ANSWERED "YES" TO ITEM 14, GIVE UNIT OR AGENCY

Na

17. WHERE ARE YOUR SERVICE RECORDS KEPT?

ACSI

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FINANCIAL STATUS.

SECTION XI

1. ARE YOU ÈNTIRELY DEPENDENT ON YOUR SALARY?

2. IF YOUR ANSWER IS "NO" TO THE ABOVE, STATE SOURCES OF OTHER

YES

ME

NO

Not Applicable,

3. BANKING INSTITUTIONS WITH WHITH YOU HAVE ACCOUNTS

NAME OF INSTITUTION

The Riggs Nat'1 Bank, Linchln Br

ADDRESS (City, State, Country)

I'th & H Street, NoW. Washington, D.C.

4. HAVE YOU EVER BEEN IN, OR PETITIONED FOR, BANKRUPTCY, : LatES YES

X. NO

5. IF YOUR ANSWER IS "YES"' TO THE ABOVE, GIVE PARTICULARS, INCLUDING COURT AND DATE(S)

6. GIVE THREE

CREDIT.

REFERENCES IN THE UNITED STATES

ADDRESS (No., Street, City, State)

NAME

SoW. Rice Co.

1342 G St. N.W., Washington D.C

The First City Bank & Irust

Fort Bragg, North Carolina

The Guaranty State Bank™

1000 Minn Ave., Kansas City Kansas

7. DO YOU RECEIVE AN ANNUITY FROM THE UIITED STATES OR DISTRICT OF COLUMBIA GOVERNMENT UNDER ANY RETIREMENT

ACT, PENSION, OR COMPENSATION FOR MILITARY OR NAVAL SERVICE? i

_YES

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.

OR WITH U.S.

CORPORATIONS OR BUSINESSES HAVING SUBSTANTIAL

FOREIGN INTEREST CORPORATIONS OR BUSINESSES: OR IN

(Il enswer "YES", fumnish details on separate sheel.)

_YES

$ NO

MARITAL STATUS

SECTION XII•

1. PRESENT STATUS (Single, Married, Widowed, Separated, Divorced, or Annulled) SPECIFY:

2. STATE DATE, PLACE, AND REASON FOR ALL SEPARATIONS, DIVORCES OR ANNULMENTS

Divorced from Monique Pierre Veber, 23 December 1947,Paris, France.

Divorce by

mutual agreement.

Divorced from Carmen Gil, 26 Mar'57, Wyandotte County, Kansas

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.

(Last).

3. NAME

(First)

Elyette

(Middle)

BROCHOT

A. STATE ANY OTHER NAMES EVER USED

NA

(Maiden)

BROCH OT

INDICATE CIRCUMSTANCES (Including length of time) UNDER WHICH ANY

OF THESE NAMES WERE USED. IF LEGAL CHANGE GIVE

(Where and by what authority).

USE EXTRA SPACE PROVIDED ON PAGE 16

OF THIS FORM TO RECORD THIS INFORMATION.

6. PLAÇE OF MARRIAGE (City, State, Country)

5. DATE OF MARRIAGE

30 March 1950

T. HIS TOR HER ADDRESS BEFORE MARRIAGE SUE GaYS, Country.

7 rue Docteur Charcot,

Seine

champigny sur lars use of DEATH

France

9, DATE OF DEATH

8. LIVING

A. CURRENT ADDRESS (Give last address, il deceased)

50 I1 Hanes Street, McLean,

Virginia

12. DATE OF BIRTH

13, PLACE OF BIRTH (City, State, Country)

4 Sept 1929

Vinh, Vietnam

SECTION XII CONTINUED TO PAGE 10

14. CITIZENSHIP

USA

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- 10 .

1A. IF BORN OUTSIDE U.S: - DATE OF ENTRY

23 December. 1956

16. FÖRMER CITIZENSHIP(S)

(Countryfies)

French

19. OCCUPATION

SECTION XII CONTINUED FROM PAGE 9

15. PLACE OF ENTRY

New Jork City,

New York

17.

DATE U.S. CITIZENSHIP 18. WHERE ACQUIRED (City, State, Country)

*CRUISERY 1959

U.S. Dist. Combt for Dist of Col.

20. PRESENT

EMPLOYER (Also

memployed give last two employer former employer, or il spouse deceased o

housewife

21. EMPLOYER'S OR BUSINESS ADDRESS (No., Sireer,

City, State, Country)

NA

22. DATES OF MILITARY SERVICE (From and to - 3y Mo. and Yr.)

24. COUNTRY WITH WHICH MILITARY SERVICE AFFILIATED

23. BRANCH OF SERVICE

NA

NA

25, DETAILS OF OTHER GOVERNMENT SERVICE, U.S. OR FOREIGN

NA

"SECTION XIll

CHILDREN AND OTHER DEPENDENTS

1. PROVIDE THE FOLLOWING INFORMATION FOR ALL CHILDREN AND DEPENDENTS

NAME.

RELATIONSHIP DATE AND PLACE OF BIRTH. #CITIZENSHIP

etrankurt

Charles M. Conein

son

30 March 150% Ger

USA

trayetterillle

Laurent P. Conein

son

19 Aprilsa50 N.C.

USA

Teh

eran

ADDRESS

4854 Kermore

Alexandria, Va

5011 Hanes St

licLean, Virginia

•Philippe Ja Conein

don

16. NOv

USA

.

2. NUMBER OF

UNMARRIED.

UNDER 21

OF AGE

AND NOT SELF-SUPPORTING.

3. NUMBER OF, OTHER-DEPENDENT-S (Including spouso,

step-parents,: sister, etc.) WHO DEPEND ON

YOU FOR AT LEAST 50% OF

THEIR

SUPPORT,

OR

CHILDREN OVER YRS. OF AGE WHO ARE NOT

SELF-SUPPORTING:

SECTION XIY FATHER (Give same

infomation

1. FULL NAME (Last-First-Middle)

toneing

Lucien Xavier

5. STATE OTHER NAMES HE HAS USED

ior Stepfather and/of Guardian on a separate sheet)

3.9 DATE OF DEATH

4. CAUSE OF DEATH

XES

X NO

1924

heart attack

ANCES (Including length of time) UNDER WHICH HE HAS

AMES. IF LEGAL CHANGE, GIVE PARTICULARS (Where

USE EXTRA SPACE PROVIDED ON PAGE 16 OF THIS

none

#-FORMTO

RECORD THIS INFORMATION.

6. CURRENT ADDRESS - Give last address, il deceased (N0., Stre,

NA

7.

DATE OF BIRTH

14 March 1872

10. IF BORN OUTSIDE U.S. - DATE OF ENTRY

NA

[Country(ies)]

8. PLACE CARIETEC

Maux,

Sein

ance

9. CITIZENSHIP

french

12. FORMER CITIZENSHIP(S)

NA

13.

DATE U.S;

ACQUIRED

14. WHERE ACQUIRED (City, State, Country)

15. OCCUPATION

16. PRESENT EM

ast employer, il Father is deceased or unemployed)

NA

17. EMPLOYER'S BUSINESS ADDRESS OR FATHER'S SUSINESS ADD

NA

18. DATES OF MILITARY SERVICE (From-and-To)

19. BRANCH OF SEF

1914 to 1919

21. DETAILS OF OTHER GOVERNMENT SERVICE, U.S. OR FOREIGN

PLOYED

20, COUNTRY

france

NMA

HH 53294 DooId:32399265 Page 11

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## Page 12

"ana!

SECTION XV..

MOTHER (Give same

information for Stepmother on separate sheet)

1. FÜLL NAME (Last-First-Middle)

2. LIVING

3. DATE OF DEATH

'4. CAUSE OF DEATH

Estelle Leontine Conein

YES

NO

NA

NA

5.

STATE OTHER NAMES SHE HAS USED

INDICATE CIRCUMSTANCES (Including length of time) UNDER WHICH SHE HAS

EVER-ÜSED THESE NAMES: IF LEGAL CHANGE, GIVE PARTICULARS (Where

Estelle Leontine Elin (maiden)

and by what authority).

USE EXTRA SPACE PROVIDED ON PAGE 16 OF THIS

FORM TO RECORD THIS INFORMATION.

6. CURRENT ADDRESS - GIVE LAST ADDRESS, IF DECEASED (No., Street, City, State, Country)

150 Monterey Street,

Brisbane,

California

7. DATE OF BIRTH

8. PLACE OF BIRTH (City, State, Country)

9. CITIZENSHIP

U.S.

6June 1893

Soengei, Dutch East Indies

10. IF BORN OUTSIDE U.S. - DATE OF ENTRY

11, PLACE OF ENTRY

22 May 1948

New Jork City, New York

12. FORMER CITIZENSHIP(S)

[Country(ies).

13. DATE U.S..CIT|ZENSHIP

WHERE ACQUIRED (City, State; Country)

French

I0 November 1959 Dist. Court, San Francisco, Cal.

16. PRESENT EMPLOYER (Give last employer, il Mother is deceased or unemployed)

15. OCCUPATIÓN

none

EMPLOYER'S BUSINESS ADDRESS OR MOTHER'S BUSINESS ADDRESS IF SELF EMPLOYED

NA

18. DATES OF MILITARY SERVICE (From-and-To)

NA

19. BRANCH OF SERVICE

NA

20.: COUNTRY

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)

T. FULL NAME (Last-First-Middle)

2. RELATIONSHIP

Brother

Conein, Maurice Rene

4. CURRENT ADDRESS (No., Street, City, Zono, Stato, Country)

unknown

Champigny sur Marne, Seine,

France

2. RELATIONSHIP

3. CITIZENSHIP (Country)

French

.. 5. LIVING

X YES

3. CITIZENSHIP (Country)

NO

6. AGE

39

1. FULL NAME (Last-First-Middle)

2

4. CURRENT ADDRESS (NO., Street, City, Zone, State, Country)

1. FULL NAME (Last-First-Middle)

2. RELATIONSHIP

5. LIVING

YES ..".NO

3.

CITIZENSHIP (Country)

6. AGE

3

4. CURRENT ADDRESS (No., Street, City, Zone, State, Country)

1. FULL NAME (Last-First-Middle)

2.

RELATIONSHIP

5. LIVING

16. AGE

YES

NO

3.

CITIZENSHIP (Country)

4

4. CURRENT ADDRESS (No., Street, City, Zono, Stake, Country)

1. FULL NAME (Last-First-Middle)

2. RELATIONSHIP

5. LIVING -

YES

NO

3. CITIZENSHIP (Country)

t6. AGE

4. CURRENT ADDRESS (No., Street, City, Zone, State, Country)

1. FULL NAME (Last-First-Middle)

2. RELATIONSHIP

5. LIVING

YES

NO

3. CITIZENSHIP (Country)

6. AGE

4. CURRENT ADDRESS (No., Street, City, Zone, State, Country)

1. FULL NAME (Last-First-Middle)

2. RELATIONSHIP.

5. LIVING

YES

NO

CITIZENSHIP (COuntry)

6.

AGE

7

4. CURRENT ADDRESS (No., Streot, City, Zone, State, Country)

1. FULL NAME (Last-First-Middle)

2. RELATIONSHIP

LIVING

YES

NO

3. CITIZENSHIP (COunts)

6. AGE

4. CURRENT ADDRESS (No., Street, City, Zone, State, Country)

3. LIVING

YES

6. AGE

NO

- 11-

1N 33294 D001d:32399265 Page 12

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## Page 13

SECTION XVII

1. FULL NAME (Last-First-Middle)

• John James Jones BROCHOT

5. STATE OTHER NAMES HE HAS USED

unknown

FATHER-IN-LAW

3. DATE OF DEATH

X/ YES

INDICATE CIRCUMSTANCES (Including length of time) UNDER WHICH HE HAS

EVER USED THESE NAMES. IF LEGAL CHANGE, GIVE PARTICULARS

and by what authority).

USE EXTRA SPACE PROVIDED ON PAGE 16 OF THIS

FORM TO RECORD THIS INFORMATION.

6. CURRENT OR LAST ADDRESS (No., Street, City, State, Country)

Noumea, New Caledonia

7, DATE OF BIRTH

8, PLACE OF BIRTH (City, State, Country)

9.

CITIZENSHIP

unk

Noumea, New Caledonia

French

10. IF BORN OUTSIDE U.S. - DATE OF ENTRY

11. PLACE OF ENTRY

NA

NA

12.

FORMER CITIZENSHIP(S)

(Country(ies)

DATE U.S. CITIZENSHIP

14. WHERE ACQUIRED (City, State, Country)

MA

15.

OCCUPATION

self employed

SECTION XYIII

1. FULL NAME (Last-First-Middle)

HA Marie Brach ot

S. STATE OTHER NAMES SHE HAS USED

NA

6. CURRENT OR LAST ADDRESS (No., Street, City, State, Country)

NA

7. DATE OF BIRTH

8. PLACE OF BIRTH (City, State, Country)

PRESENT EMPLOYER (Give last employer, if Father-in-Law is deceased or unemployed)

self emolayed

MOTHER-IN-LAW

2. LIVING

3. DATE OF DEATH

4. CAUSE OF DEATH

| YES IT NO

X*A- 1947

cancer

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.

NA

9. CITIZENSHIP

French

10. IF BORN DUTSIDEAU.S. - DATE OF ENTRY

11. MACE OF ENTRY

12. FORMER CITIZENSHIP(S)

(Country(ies)

13. DATE U.S. CITIZENSHIP

14. WHERE ACQUIRED (City, State, Country)

ACQUIRED

NA

NA

15. OCCUPATION

10..

PRESENT EMPLOYER (Give last employer, it Mother-in-Law is deceased or unemployed)

NA

NA

SECTION XIX

RELATIVES BY BLOOD,

MARRIAGE OR ADOPTION WHO EITHER (1) LIVE ABROAD,

(2) ARE NOT U.S. CITIZENS OR (3) WORK FOR A FOREIGN GOVERNMENT

1. FULL NAME (Last-First-Middle)

2. RELATIONSHIP

CONFIN, Maurice Rene

brother

4. ADDRESS OR COUNTRY IN WHICH RELATIVE RESIDES

5. EMPLOYED BY

2

Champigny sur Marne, Seine France

6. CITIZENSHIP (Country)

7. FREQUENCY OF CONTACT

unknown

8. DATE OF LAST CONTACT

french

seldom

16 Sept 61

1. FULL NAME (Last-First-Middle)

2. RELATIONSHIP

BROCHOT, Joh n James Jones

f, ther in law

4. ADDRESS OR COUNTRY IN WHICH RELATIVE RESIDES

5. EMPLOYED BY

Noumea, New Caledonia

self embloyed

6. CITIZENSHIP (Country)

French

7. FREQUENCY OF CONTACT

have never seen

8, DATE OF LAST CONTACT

never contacted

1. FULL NAME (Last-First-Middle)

2: RELATIONSHIP

3. AGE

39

3. AGE

und

3. AGE

4. ADDRESSOR COUNTRY IN WHICHIRELATIVE RESIDES

5. EMPLOYED BY

6. CITIZENSHIP (COunIry)

I. FREQUENCY OF CONTACT:

B. DATE OF LAST CONTACT

1. FULL NAME (Last-First-Middle)

2. RELATIONSHIP

3. AGE

4. ADDRESS OR COUNTRY IN WHICH RELATIVE RESIDES

5. EMPLOYED BY

6. CITIZENSHIP (Country)

7. FREQUENCY OF CONTACT

8. DATE OF LAST BANIACT

•SECTION XIX CONTINUED TO PAGE 13

HIT

53294

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## Page 14

SECTION XIX CONTINUED FROM PAGE 12

6. SPEEIAL REMARKS, IF ANY, CONCERNING RELATIVES NOTED IN SECTION XIX ABOVE

SECTION XX

1. NAME (Last-First-Middle)

RELATIVES BY BLOOD, MARRIAGE OR ADOPTION WHO ARE IN THE MILITARY OR CIVIL

SERVICE OF THE UNITED STATES

2. RELATIONSHIP

3. AGE

4. CITIZENSHIP

NA

5. ADDRESS (No., Street, City, State, Country)

6. TYPE AND LOCATION OF SERVICE (11 known)

1. NAME (Last-First-Middle).

2. RELATIONSHIP

3. AGE

14. CITIZENSHIP

5. ADDRESS (No., Streer, City, State, Country)

6. TYPE AND LOCATION OF SERVICE (11 known)

1. NAME (Last-First-Middle)

2. RELATIONSHIP

3. AGE

A. CITIZENSHIP

5. ADDRESS (No., Street, City, State, Country)

6. TYPE AND LOCATION OF SERVICE (1f kriown)

SECTION XXI

REFERENCES, ACQUAINTANCES, AND NEIGHBORS

1. LIST FIVE CHARACTER REFERENCES, NOT RELATIVES, IN THE U.S., WHO KNOW YOU INTIMATELY

NAME

(Last-First-Middle):

BUSINESS ADDRESS

- (No?, Street, City and State)

RESIDENCE ADDRES:

(No.; Street, City and State)

B/Gen Edw, G. Lansdale

Of Ass't Sec Defe

Mr. Lucius 0. Rucker

CIA

Hon. Errett ?. Scrivner

congress

4503 Mac Arthur Blvd

Washington, Dotio

5011 Hanes Street

Me Tean, Firginia

2331 Cathedral Av.N.H.

Washington, DoG,

arlington lowers

Mr. 17 Fred I. Cox

CIA

U.S. Embassy

Mr. John Foster

CIA

Teheran, Iran

2. LIST FIVE PERSONS, IN THE U.S. WHO KNOW YOU SOCIALLY - NOT RELATIVES, SUPERVISORS OR EMPLOYERS

NAME

(Last-First-Middle)

BUSINESS ADDRESS

RESIDENCE ADDRESS

(No., Street, City and State)

(No., Street, City and State)

Since I have Been in the military Service since September 1941 and since

since the majority of my military service has been in overseas areas, specifically

since 1959, 1961, and since I have just returned from Teheran, Iran, my social

contacts are.not in the United States.

NAME

(Last-First-Middle)

3. LIST THREE NEIGHBORS AT YOUR MOST RECENT NORMAL RESIDENCE IN THE U.S.

BÜSINESS ADDRESS

(No., Street, City and State)

RESIDENCE ADDRESS

(No., Street, City and State)

Same as above applies. In

the military service people are being continuously

transferred to new duty stations therefore at this time it is impossible to

adequately answer this question.

- 13

HH 53294 DocId: 32399265 Page 14

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## Page 15

• 14

SECTION XX'II

CLUBS, SOCIETIES, AND OTHER ORGANIZATIONS

NOTE: Lisi 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.

NAME AND CHAPTER

(Number, Streer,

(ODy, State. Country)

DATES OF MEMBERSHIP

FROM

TO

Airborne Association

Ft. Bragg, North Carolina

1956

pres

Reserve Officers Association

Washington, D.C.

Assoc of U.S. Army

Washington, D.C.

1957

1958

pres

pres

SECTION XXIII:

RESIDENCES FOR THE PAST 15 YEARS

ADDRESS - LAST RESIDENCE FIRST

(Number, Street, City, State, Country)

INCLUSIVE DATES

FROM

Agency mission to Germany

1946

1512 Ellison Street, Falls Church, Virginia

Aug 153

Agency mission to Vietnam

June 15h

13 Maas Drive, Ft. Bragge North Carolina

NoT 156

159

No 5 Kuchi Safa, Teheran, Iran (Mil Liaison Gp. APO 205 NY)

Sept 199

TO

1953

June 154

Oct: 156

Aug 159

Sept '61

1N 53294

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Page 15

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## Page 16

•SECTION XXIV

ADDITIONAL INFORMATION

1. OR HAVE YOU EVER SUPPORTED

HAVE YOU EVER

OR

SEEN ASSOCTATE

OR ARE

ASSOCIATED WITH'ANY

POLITICAL

IZATION WHICH ADVOCATES OR TEACHES THE OVERTHROW OF

HER RIES MER

UNCONSTITUTIONAL

THE

GOVERNMENT OF THE UNITED STATE!

R SEEKS BY FORCE OR VIOLENCE TO DENY PERSON

THE CONSTITUTION OF THE UNITED STATES?

2. IF YOU HAVE ANSWERED "YES" TO THE ABOVE QUESTION, EXPLAIN

YES

NO

3. DO

YES

4. IF SO, TO WHAT EXTENT?

NO

TO WHAT EXTENT

• EVER USED NARCOTICS?

7. HEATION OF YES ACFEMAIMEMBER OF, OR SUPPORTED, OR HAD ANY CONNECTIONS WITH A FOREIGN INTELLIGENCE ORGAN-

INO

IF ANSWER IS "YES", GIVE COMPLETE DETAILS.

Military Liaison to J-2 SCS, Imp Iranian Army 1959 to 1961

8. PLOYMENT SINCE NAMES OF GOVERNMENT DEPARTMENTS, AGENCIES OR OFFICES TO WHICH YOU HAVE APPLIED FOR EM-

U.S. Army

9. AGENCY UR THE APPROXIMATE DATE OFOYEE AVE STINATIOND AN INVESTIGATION OF YOU, INDICATE THE NAME OF THE

OSS 1943

U.S. Army 1956-57

SSU 1946

ACSI D of A 1959

GIG 1947

CIA 1948-49

NOTE SPECIAL

INSTRUCTIONS

to more ro o he aleing Que no all his fori do the information requested for dach

IN ACCORDANCE WITH THE SPECIAL INSARUC FION ARO LATE, NATURE OF OFFENSE AND DISPOSITION OF CASE

YES

X NO

YES

I NO

YES

I NO

.

ULATIONY IF SO,

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

PLANATION?

DESCRIBE

FOR AN WITH SPECIEST RECTIONS SOONE

SECTION XXV

1. NAME (First-Middle-Last)

Flyette Brochot Conein

3. HOME ADÉRESS (No., Street, City, Zone, State, Country)

PERSON TO BE NOTIFIED IN CASE OF EMERGENCY

2. RELATIONSHIP

A. HOME PHONE NO.

FImWOOd 6-1,811

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

0x 57742

7. 15 NOT DESIRABEE. ENCAUSE OF HEALTH DEÔTHER EASONS, PLEASE SO STAY ELSO BE NOTIFIED. IF SUCH NOTIFICATION

Irs. Estelle Conein. 150 Monterey St. Brisbane. Calif. Mother

- 15 .

HW 53294 DocId:32399265 Page 16

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## Page 17

SECTIGE XXVI

CERTIFICATION

•YOU ARE INFORMED THAT THE CORRECTNESS OF ANY STATEMENT MADE IN THIS APPLICATION.

WILL BE INVESTIGATED.

have read and understand the instructions. I Certify that the foregoing answers are true and correct to the best of my

knowledge and belief.

lagree that any misstatement or omission as to material fact will constitute grounds for immediate

dismissal or rejection of my application.

l.also understand that any false statement made herein may be punishable by

lam (U.S. Code,

1. DATE OF SIGNATURES

2. SIGNATURE OF APPLICANT

25 deptEmber 1961

3. SIGNED AT (City and State)

4. SIGNATURE OF WITNESS

Washing tons

C.

Kirit

NOTE: Use the following space for extra details. Reference each continued item by section and item number 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

page and sign each such page.

NN 53294

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Page 17

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