U.S. DOCUMENT REQUEST FORM.
Agency: CIA
Originator: CIA
From: DO/SEC
To: OFFICE OF SECURITY
Document date: 12/10/71
Document type: PAPER-TEXTUAL DOCUMENT

## Page 1

104-10121-10219

SECRET •

Case, No.

(Do not write in this space)

Dale: 10-09077--

U.S. DOCUMENT REQUEST FORM.

REQUESTS FOR U.S. ALIAS DOCUMENTS FOR USE IN U.S.

REQUIRE APPROVAL OF OFFICE OF SECURITY

Requesting Ofice:

Does

Registered Alias

NEGO

(Write out middle name, if any)

Backstopped address, if any:

If address is to be selected by TSD, list state and cities with which you are familiar in order of preference:

First choice:-

flasida) /

Second choice:

Third choice:

Height: 5 // Weight: 198

- Hair:/

Cir. Eyes: -

Our Blood Type: K. Married?-

Glasses while driving?

10_ Birth date:-

(26 AUG 1925 Place: PAGENIX ITE

Occupation:

INTELL OFFICER

Race:

(Engineer, Intelligence Officer, Government Official, etc.)

(White, Negro, Yellow)

Specify country where documentation will be used:_

Documentation requested:-

LITTER.

As a guide for issuance of appropriate documents, list hobbies, i.e., photography, bowling, shooting, stamps, etc.,

special interests, social clubs, athletic and cultural associations, or professional societies or institutions with which

you are familiar:

Signature exemplar in alias:-

(Write name three times)

Supply proper photo or negative for identity document request if required.

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