FORM 15A: PERSONAL RECORD QUESTIONNAIRE
Agency: CIA
Originator: CIA
Document date: 01/01/0000
Document type: PAPER-TEXTUAL DOCUMENT

## Page 1

104-10220-10302

•2248

PERSONAL RECORD QUESTIONNAIIE

PART I1 - OPERATIONAL INFORMATION

TRUCTIEAS

wwY..

ge 1.178;

an, rearit.ne:".

#: (5 70-15-19

to cristete

gut, 1219-91141

COMTACTED ON DEU

tionl ToVer:

17,5 0

CASE OFFICEAS WHO MAVE MAGGLES SUBJET OS

mti.e

1050a

SECRET

• 1 100

beat

WHICH THEY MAYE

18-801

---

## Page 2

• SECRET

eine i 1's

6 511%

@VER THE DUBIRES. (AD

401 81889)

Tre sartro cactor is a rublisslo: si subjech diat da procent epmearo

mly canco ho has at returming to Qua

SECTION 110

- CONCE

COVER VOED DU DUBIRCI AND CASE OFFICEA IN PARTA MELTONGS.

ІОН ОНО ОБ ССОРОСТОНЛВ ІНІОТИАНТ:

Subdert. 19.65

overt official of an over or entter ene obera incounte

purposen of tiet organizailor

saueraine

SECTION IV

INTELLIGENCE CONNECTIONS AND TRAINING

OR PRESINI CONNECTION

WIIN ANY BIERE DOTELLOCANCE ACOVICE.

JUCH CORANCHION IN NNOMA OVE

155p6=-42

3 20

LIST OTHER

Priondo) tro 1930 10

== 30rig: 1021711125,

ti:at ito

is o banien di the Cort moezeratis

AMY

MAS HAD IN CAINOLSTINE OPIE

Nene

COLLABORATION POTENTIAL -

ASSOCIATitAS.

er n Miet,

sagunie.

SECREr

---

## Page 3

"SECRETAr

OPERATIONAL 956. 2 CON IAGE

torcise scruel, re

INDICatE nON AND enDa mon sUBJECt

001A1n8 Inta

180H.

may pe dominice data

cogs 1o incon to other coriolae of to ocentsation.

THAT DAS DELA IOLO SUBJECT. ABLTO THE DISPOS

0#-

sol,gest has bee sole shat the unta le furilahon 1e use. by tuc pivate duerien

7.234

A. DASAIL DUDJECR O PROPODO PI ON CI TYPE USE ON DU!

Do ma orricial dra tront

troug

pannona, by:

numer ts to furr

He dutacs.

tho erroto ch

tho

a24

PROPOSED LIAISON/OR

A. OMENA BUDDICT IS EN DEFICIAL MINDIN OF A FOREIGN GOVERNMENTI

nt..

# #HERE BUNJEET

OFFICIAL

MENDEA OF AM DOVOKE

AGRACTEr

SECTICE VIII

AGENCY RELATIONSHIP WITH SUBJECT

EXPLAIN NATURE OF AGCACI

RELATIOSSNID MIYA SUBIICE:

PERSONNEL ANONN

TO SUBAICE.

SPPOSITE UNDER, DRGOTKRATION ME ANYO

NGENCY

.

:?"

spires :

 the.

i:t.:"

SECRET

---

## Page 4

I SECRET

SECTION EX

 0#

dtad"..

QU AL

sunsch mich coulo concei

SECTION I

DARN I THEN TS

SUBJECT A REGULAR SALARY.

SPECIEY. AND

Node

jo earitacres nade.

TION XI

INDICATE THỊ

Bavans stetion illes;

INDICATE OTHER

Kona

HARACARE

WHETHER OR

PAQVAL BOR SUBJECT'S USE HAS

BEEN

AL-OR GPEDATIONAL

ROMAR 1698

airwarch agos

EVALUATE

Subjoot 8e charcotr

sceng

LANCE AND SECURITY, COME EY

constotent alta to racke nom

Nas

bein

B- ERPLAIN

TaiD

AAY

SITUATEUR

INDISCRETION, IN NHICH SUBJUGE MAY MAVE BECA IMVOLVEO UMICH MUST BE EVALUATIO FRONA

CE/OPERATIONAL SECURITY VIEST

SECTION- HAD

USE OF LIQUOR, DRUGSI

SECRET

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## Page 5

GENERAL

IS H8 COULD PARS.

MEORMATION IN PRO MARIO A AND 1A MAN OBTAINER

CONDITIONS RECOAT

MAP, BOk A

X98

MISCELLANEOUS OPERATICIAL DATA AND REMARKS

#ano

-27"

see:

SICRATURE SO APPACUMIATE

SENDA OFFICER

isst1i1

$

SECRET

---

## Page 6

SERGET

PART

QUESTIONALIE

11 - OPERATIONAL INFORULIION

• лЕ

INSTRUCTICA, TO CASA OFFICER

+P5H0NN9 10011400

sia d 196.

DR?h00d8y 09 PAO DOODO Of INO BOAT ANNICABIA IN.

arisera

ley

• ПІД ЧИВОРом

HORMONDO

rallo dento, son.

@uppect a sandmenond, 1l 000010001 0n810012) cree

possible.

##EUDONTA

11p11al",

SECTION

COMTACT ONE ILVLLOPRENT

GONICATE MUM.

BORN, OHERE.

#HY.

AND BO ANON SUOIEC? DNI DINSO CONTACIEO OR DEUCESTEO.

diariend to terman?:

Christeni

два? десаія 1'4

Cola.

to centration wen cle

see de conceite die pring deed men wee would gated de lahar Ilterutteri

morons??"

HOTCAT

1310s.

TOMED GUER GUILOLE MOU DO A SECURE MANNER TO LEE DESOLE CASE DErICK oN

Dote sort

' Ci

TIST ATRE CASE OFFICENS PO HAVE MEGOLE SORTECT CO

ME TONS ON HAS MADO, TOE DAMES ON SNICH THEY NAVE

80501 1504

108-41

SECRET

---

## Page 7

• 1.a}

SECTOR !!

i constant. *y

Me carati

AMAT CONTROL.

pipenin. y

anly chance lis har

SECRET

NUTIVATIUR AN, CUBING

arresto 4600 694088101 DOlle BOUrn

Do nod uno dierd lumand

But i do

"3-1N

lotties sign eye drone

reple to partin tree.

do an elident dealer.

22048 D9 10 JORDaRs 04 08) •999C008 81L 8390 82818) "ANY

SECTION II1_

COVER

COVER VERD DY DUBIRCE AND CASE OFFICER IN PURIA MEETINGS:

si hemlouardors in En A"ralean

city; contact sla the do variro mut Includes too soo do dude bones factlities.

COVER UBRO DY SUBJECE IN DOTAINING NIS INTONMATION AND L9 CEUTACTING HIS INTURMANIO.

Subjant 19 so overt pellelad me an overd creamera En: dintos arcoraction for Lia

INDICATE DARNICA FOR MUICH SUDDECT THINKS ME POLIS

0841-688-84851548

Caboot mole mecure tet hole warriag

SECTION BY

INTELLIGENCE CONNECTIORS ARE TRAINING

KARLAIN

SOILET'S KNOWS PAST OR PRESINT COUNEEIDOR

WIR DT RITEST DOC SERVE TOTEAT TOP PETENT

SUES COMBESID 1E KNOWA OVINTAY.

areth Moon that

+ 178S12281EN 191219A 191219A 8-193/996 O907 DER POPURIO

warg

incidenton.

¿APLANA ANY TRAINING SOOJECE DAS NAO IN CLANDESTINE ORIENTAGO?.

SECTION Y

COLLABORATICA POTENTIAL

INOICATE

0:406

SORRICA POOLA SUNILES MOULD DE MUSE LINGE

ASSOCIATILAS, KAPLAIN.

tines, iris ladent, toiled with. "

SECRET

....

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## Page 8

XUDJEEPHAS

9D86 NO CONTAL IS DIADRE.

MANUR DA MAN PEDINGOES.

SECRET

OPERATICHAL

USE - CONTACI

160194"1

ACTIVITO I MAILOME DAS GAGAGED AND TOF TYPE ON 19000.

SODICATE NOS ANO BRIN MMON DUBLICA DOTAINS ITOMNATION.

carpoot le as castered of on cout dogence, stand, which in de interest to

Gan!

rumicro date on sno mucisatio! do part of lab official ruties.

"This

tact lilncha bi other africhris of tie a genisaton.

INDICATE

SAY MÃS OLLO TOLD SUBJECE AB TO PHE DISPOSITION OI INPONNATIDA ME FURNISHES.

A, ORIAIS BUODECT-S PROPODED PI ON CI TYPA USE DR DUTIES.

H.n.

SNOJECT•S PREPOSTA SP-PA TYPE USE OR DUTIES.

A dotaus and to sundoor

nia capeein; scrolline lo such armer de to dodece ton orcard et taudrea

SECTION YII

PROPOSEN LIAISON OR OPERATIOMAL ACTIVITY

PE WHENE SUDARGE DS DO CRAIGIN MINNIE DO A PORCIEN GOVERNMENTS

E, MIERE SURIECE IS

А ОПРАСТ MLMBEN ОТ

as parant

SECTICH WATI

AGENCY RELATIONSHAP WITH SUBIECT

SALAIL

MATUNE AS AGEOLA BELATIONSMIP MIN SUDDICE DE, THAINER, IPPOSITE NUMBEN, RENUVIRATION, IF ANT, ARENCY

SUSHICE.

"?:"

i satis

..:

'r":

:.1.

SECRET

t nove.

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## Page 9

SECRET.

SECTION 1X

ADILITIES.

QUALIFICATIONS FOR ONER OPTRATIONS

TALLAPS, OR QUALIFIÇATIONS POSSESSIO DY SUBJAGE MEIEM COULU CONCHIYABLE DE OF VALUR

IOR SiTHER GRANATIONS.

SECTION

COMMI THENTS

iS IT IS PROPOSEO YO PAY SUALICE A MREULAN SALADY.

INDICATE SUE BLINLY AMQUNS, NO DAUMENT TO DE MADE IN ENCHANGE.

COMMODITIES, SUASION ON OTHER METHOO, SPICITY ANO GIVE DETAILS.

of aubject and tasti

No cormitmonto made.

OTHERHODE NOT COVERCO MERLIN.

MADE TO

SUOLICT. (Esample:

Coma

SECTION

INDICATE

CE AND. SECURITY.

SU@JECT'S NAME

H4A5

AIRMANECHLY AND

THE RESULTS.

THE FACED' AGENCIES

AND FIELO PILED MITH MICH

Havar merlon 11057, 1i.

INDICATE OTHER INVESTIGATIVA

MEATURES TAXEN TO VERIFY BIOGHAPHICAL INFOOMATION FURRISHEO BY SUBURET.

Were

INDICATE

WHETHER

OR

40P.PHOVIS8ONAL

DPENATIONAL

APPROYAL OR OPIAATIONAL AP,

THEYEAR

SUBARCT'S USE HAS

GLEN PREVIOUSLY DOTAINED.

EVALUATE SUBJECT•S ENARACTER, RPLTADIOTTY AND SECURITY. COTING EVIDENCE WHERE POSSIBLE.

660 101610191 O1S G910441021

DATE APPRObAL DOTAINED

21 Vorch 1903

B. EXPLAIN ANY SITUATION

OR INDISCRETINN IN WHICH SUBSLOT MAY MAVE GLEN INVOLULO AMIL MUST DE EVALUATED FROM A

CE OPERATIONAL SECURITY

Fer..:

VIEBPOINT.

SECTION XIL

SUOJECT'S PERSONAL HABITS

USE DE LIQUOR. DRUGS.

CAMAL IME, HAMAMONAS.

SECRET

" sets restin mentire sain.

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## Page 10

SEC7:0A 8111

SECRET

AVOCALICHAL

MUSIC.

INTERESTS

!.$7:49

Parat.

SECTION,

NIV

CEMERAL

ANDICATI ВНЕТНЯ

SUBJECT"S LANGUAGE ABILITIES ANO

DININ CHARACTERISTICS, ARE SUCH ÀS ME COULD PASS AS A GATIVE

A COUNTRY

DA REGION OBNEN AMAN HIS OON.

AAPLAIN.

No

IADICATE

WHE TARN

INFORMATION

COANISPOMDRACE ON OTHEN MINS.

11 PRO PARTO I ANO 10 MAS OBTAINBO dY RESEARCHi GLANDESTINE ASSESSMENT.

FILES.

tre caren

POTHER TURE AOUDINE ACTION IS REQUIRED, IS AND WHEN FERMINATIDN OR SUILEGE 19 AFFECTED.

PLEASE RIFLAIN. (AISO

f.д.

SECTION XV

EMERGENCY CONDITIOHS RECONTACE ARRANGEMENTS.

GIVE FULL

DETAILS 1.E, BECOGNITIDN SIGNALS, SINI ANCHA COURO COLÁCE BR MADE WHAT BOMA TIDES COULO INCIVIOUAL

MACING SCOTICE USES

SECTION XVI

MISCELLAMEOUS OPERATICHAL

DATA

AND REMARKS...

DATE

SIGNATUNA DO APNADIHIATE SENTIO OFFICER

SECRET

:.?.

•--.

• Endore

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