SUPPLEMENTAL PHS OF JAMES WALTON MOORE.
Originator: CIA
From: CIA
To: CIA
Document date: 01/11/1950
Document type: PAPER - TEXTUAL DOCUMENT

## Page 1

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104-10124-10218

2022 RELEASE UNDER THE PRESIDENT JOHN F. KENNEDY ASSASSINATION RECORDS ACT OF 1992

SUPPLEMENTAL PERSONAL HISTORY STATEMENT

1. NAME (First-middle-last)

. 2.

NAFITAL STATUS

SIAGLE

Jenes Walton Moore

X MAFFIES

3.

1I MARRIED

NAME OF SPOUSE

(First-middle (maiden)-last)

Fatricia Anslev Moore

PLACE OF MARRIAGE

IDATE OF MARRIAGE

Lashington,

C..

12 AUr 41

RESIDENCE (Since date of last PHS, il overseas residence indicate

only city & country)

SINCE (Date)

NUMBER AND STREET

CITY AND STATE

PRESENT

August 1954

DATE TO DATE

5145 Rexton Lane

NUMBER AND STREET

Dallas,

Texas

CITY AND STATE

FROM

Apr 54 to Jul 54

DATE TO DATE

3406 Dartmouth

NUMBER AND STREET

Dallas, Texas

CITY AND STATE

FROM

Jun 50 to ADr 54

3502 Underwood

Houston, Texas

5. HAVE YOU

BEEN ARRESTED.

INDICTED. OR CONVICTED FOR

ANY VIOLATION

oF LAw (Other than for

minor traffic violation) SINCE THE DATE OF

YOUR LAST PHS

6. SINCE, THE DÄTE- OF

YOUR LAST

PHS. HAVE THERE BEEN ANY UNFAVORABLE INCIDENTS IN YOUR LIFE

WHICH MIGHT REQUIRE EXPLANATION

7. NAME OF YOUR PRESENT IMMEDIATE SUPERVISOR

EXT.

RV. #,

Ernest A Rische, Houston,

Texas

8. ADDITIONAL REMARKS (USe reverse if necessary)

• CTHEK

bES. Explein

NO

DATE

..

444e

SIGNATURE OF EMPLOYEE

RETURN TO CIA

Background Use Only

RIN: SM

---

## Page 2

PERSONAL HISTORY STATEMENT

Instructions:

1.

Answer all questions completely. I question does not apply write "not applic-

able."

Write "unknown" only if you do not know the answer and cannot obtain

the answer from personai records.

Use the blank pages at the end of this form

for extra details on any question or questions for which you do not have suff-

cient room..

Type, print or write carefully; legible or incompleté forms will not receive con-

HAVE YOU READ AND DO YOU UNDERSTAND THE INSTRUCTIONS?

Yes

Ies or No

SEC. 1. PERSONAL BACKGROUND

Telephone:

NDrES

A. FULL NAME Mr.

(Use No..:

Instlals)

Walton

Middle

Moore

Omice:

Ext.

PRESENT ADDRESS

2600 Pemberton Ave.,

" Houston,

? Техав:

St. & No.:

State

PERMANENT ADDRESS

2457 lalewild St., Abilene, Texas:

st. & No.

City

Btate

B. NICKNAME Jin - Jimmie

- WHAT OTHER NAMES HAVE YOU USED?

Home:

• USA *

country:

USA 1.

country:

None

UNDER WHAT CIRCUMSTANCES HAVE YOU EVER USED THESE

NAMES?

Not applicable

HOW LONG?

IF A LEGAL CHANGE, GIVE PARTICULARS

Where?

C. DATE OF BIRTH 5 Oct 1919 PLACE OF BIRTH_ Far twell

D. PRESENT CITIZENSHIP -

US

Country

BY-BIRTH,-

By What Authority

Georgia

State

Yes

_ BY MARRIAGE?

Country

BY NATURALIZATION CERTIFICATE #

ISSUED

Dato

BY

Court

AN

AT

Cily

State

Country

"4?3

HAVE YOU HAD A PREVIOUS NATIONALITY?

NO

HELD BETWEEN WHAT DATES?

_ TO

Yes or No

COUntry

ANY OTHER NATIONALITY?

Country

GIVE PARTICULARS

NO

HAVE YOU TAKEN STEPS TO CHANGE PRESENT CITIZENSHIP?

GIVE PARTICULARS:

FORM NO.

SEP IDAD

3B.1

---

## Page 3

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E. IF BORN OUTSIDE U.S. WHEN DID YOU FIRST ARRIVE IN THIS COUNTRY?.

PORT OF ENTRY?

ON PASSPORT OF WHAT COUNTRY?.

LAST U.S. VISA

Number

Type

Place of Issue

Date of Issue

SEC.

2. PHYSICAL DESCRIPTION

30

Male

6°

AGE

SEX

HEIGHT

WEIGHT

190 lbs

brown

EYES

bornw

HAIR

COMPLEXION -

medium

SCARS

nOne

BUILD

average

_ OTHER DISTINGUISHING FEATURES

SEC.

3. MARITAL STATUS

A. SINGLE

MARRIED

x.

- DIVORCED

WIDOWED

STATE DATE, PLACE, AND REASON FOR ALL SEPARATIONS,

DIVORCES OR ANNULMENTS

2406943

(IF YOU HAVE BEEN MARRIED MORE THAN ONCE - INCLUDE ANNUL-

B. WIFE OR HUSBAND

MENTS- USE A SEPARATE SHEET FOR FORMER WIFE OR HUSBAND

GIVING DATA REQUIRED BELOW FOR ALL PREVIOUS MARRIAGES.)

Alyce

Patricia"

Ansley

Moore

NAME OF SPOUSE

First

Middle

Maiden

"Last

PLACE AND DATE OF MARRIAGE -

*Washington, D. C., April 12, 1941

HIS (OR HER) ADDRESS BEFORE MARRIAGE 857 ROSs Ave., Abilene, Texas

Country

LIVING OR DECEASED Living

- DATE OF DECEASE

CAUSE

PRESENT, OR LAST. ADDRESS 2600 Pemberton Ave., Houston, Texas, U.S.A.

DATE OF BIRTH 28 NOT. 191 PLACE OF BIRTH

Houston, Texas, USA

IF BORN OUTSIDE U.S. INDICATE DATE AND PLACE OF ENTRY

CITIZENSHIP

US:_ WHEN ACQUIRED?

housewife

WHERE?

City

FBI

State

Country

OCCUPATION

EMPLOYER'S OR BUSINESS ADDRESS

MILITARY SERVICE FROM -

LAST EMPLOYER

Washington, D.C:

St. & No.

TO

USA T

Date

State

_ BRANCH OF SERVICE

Country

Dare

COUNTRY

- DETAILS OF OTHER GOV'T. SERVICE, U.S. OR FOREIGN

---

## Page 4

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SEC. 4, CHILDREN OR DEPENDENTS (Include partial dependents)

1. NAME Michael Malton Hoore

_ RELATIONSHIP

Son

6

AGE

CITIZENSHIP _

US

_ ADDRESS 2600 Penberton, Houstch, Texas, USA

Country

2. NAME Kergaret Lee Moore

_ RELATIONSHIP Daughter

- AGE

•-5 :

CITIZENSHIP US

ADDRESS

2600 Pemberton, Houston, Texas, USA

SEC.

3. NAME.

RELATIONSHIP

AGE -

CITIZENSHIP

_ ADDRESS

St. di No.

Ciry .

State

Country

FATHER (Give the same information for stepfather and/or guardian on a separate sheet)

is g

FULL, NAME

Jane's

Talton

Moore

Last =

WVING OR DECEASED Deceased D.

DATE OF DECEASE Dec. 1938

- CAUSE Cancer

15S6e 2254

PRESENT, OR, LAST, ADDRESS 1701. Shofer SteAbilene, Teres, USA ou

DATE OF BIRTH.

1889

_ PLACE oF BIrTH lurphy County, N. Carolina

country

IF BORN OUTSIDE U.S. INDICATE DATE AND PLACE OF ENTRY -

CITIZENSHIP

- WHEN ACQUIRED? -

OCCUPATION Missionary

— LAST EMPLOYER Baptist Foreign Mission Board

EMPLOYER'S OR OWN BUSINESS ADDRESS Louisville, Kentucky.

USA

Bt. & No.

state..

country

MILITARY SERVICE FROM

1917

_ TO 1918 BRANCH OF SERVICE _

US Army

COUNTRY

DETAILS OF OTHER GOV'T SERVICE, U.S. OR FOREIGN.

SEC. 6. MOTHER (Give the same information for stepmother on a separate sheet).:

FULL NAME Hinnie

First

Leo

Moore

MIlddle

Last.

LIVING OR DECEASED Living

_ DATE OF DECEASE

CAUSE

PRESENT, OR LAST, ADDRESS 711 South 5th Streot, Taco, Ioxas

DATE OF BIRTH _

1892

_ PLACE OF BIRTH _

MoLemne Texas

CITIZENSHIP US

WHEN ACQUIRED? -

_ WHERE?

City

IF BORN OUTSIDE U.S. INDICATE DATE AND PLACE OF ENTRY

USA

Country

Btste

COuntry

---

## Page 5

OCCUPATION -

housewife LAST EMPLOYER

EMPLOYER'S OR OWN BUSINESS ADDRESS

Bt. & No.

City

Brate

MILITARY SERVICE FROM -

- TO

BRANCH OF SERVICE

Country

COUNTRY:

DETAILS OF OTHER GOVT SERVICE, US. OR FOREIGN.

SEC.

7. BROTHERS AND SISTERS (Including half-, step, and adopted brothers and sisters)

1. FULL NAME

Martha

Jane

First

Niddie

PRESENT ADDRESS -

Monna Carroll, Illinois

St. & No.

City

Hutchins

I9st

USA

country

FULL NAME

Wafford

PRESENT ADDRESS

Pittsburg, Penna.

3. FULL NAME -

Betty

First

PRESENT ADDRESS

71le S. 5th Street,

Bt. & No...

City

1.R47

Waco,

Texas

USA:

Country

4.

FULL NAME

First

Middle:

PRESENT ADDRESS

Bt. & No.

City

Btate

Country

5, FULL NAME

First

Middle. i

PRESENT ADDRESS

St. & No.

City

State

Country

SEC.. 8. FATHER-IN-LAW

FULL NAME:

William

I5Bt

0.

Ansley

Middlo

AGE

32

US

Citizenabip."

27

USad

Citizensal,

Inst

AGE

US

Citizenship

AGE

last.

Citizenship

I28t

AGE

Citizenship

last

LIVING OR DECEASED LiViNg DATE OF DECEASE -

CAUSE

PRESENT. OR LAST, ADDRESS 857 Ross ATenue, Abilene, Texas

".

DATE OF BIPTH -

1889

_PLACE OF BIRTH

Houston, Texas

U. Seni

Country

IF BORN OUTSIDE U.S. INDICATE DATE AND PLACE OF ENTRY

CITIZENSHIP

WHEN ACQUIRED?

WHERE?

CIty. Brato

Partner of Hoffman Eleot. Supply Co.

Count

OCCUPATION

_ LAST EMPLOYER Foffman Electrical Supply co.

---

## Page 6

SEC. 9. MOTHER-IN-LAW

FULL NAME:

SEC. 10.

SEC. 11.

Largaret

FirBt

Middle

LIVING OR DECEASED LiViNg DATE OF DECEASE

Ansley

LEBt

CAUSE

PRESENT, OR LAST, ADDRESS 857 ROss Avenue. Abilene, Texas

DATE OF BIRTH

- PLACE OF BIRTH

San Antonio, Texas

USA

Country.

IF BORN OUTSIDE U.S. INDICATE DATE AND PLACE OF ENTRY.

CITIZENSHIP

_ WHEN ACQUIRED?

WHERE?

state

country

housewife

OCCUPATION

LAST EMPLOYER

RELATIVES BY BLOOD, MARRIAGE OR ADOPTION, WHO EITHER LIVE ABROAD OR

WHO ARE NOT CITIZENS OF THE UNITED STATES:

170055

NAME Not applicable

RELATIONSHIP

AGE

CITIZENSHIP

ADDRESS

NAME

Be. & No.i

.9.2023A5

RELATIONSHI:

olty

Stato

Country

AGE

CITIZENSHIP

4, 4-.

ADDRESS

City

State

country

3. NAME

RELATIONSHIP

CITIZENSHIP

ADDRESS

Be. & No..

City...

Btate

Country

RELATIVES BY BLOOD OR MARRIAGE IN THE MILITARY OR CIVIL SERVICE OF

THE U.S. OR OF A FOREIGN GOVERNMENT.

1. NAME

Not applicable

RELATIONSHIP

- AGE

CITIZENSHIF

ADDRESS

Bt. & No.

City..

state :

TYPE AND LOCATION OF SERVICE (IF KNOWN)

2. NAME.

RELATIONSHIP

_ AGE -

CITIZENSHIP

ADDRESS

Bt. & No.

City

State

TYPE AND LOCATION OF SERVICE (IF KNOWN)

3. NAME

RELATIONSHIP

AGE

CITIZENSHIP

ADDRESS

st. & No.

City

State

TYPE AND LOCATION OF SERVICE (IF KNOWN)

5

---

## Page 7

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6

SEC. 12. EDUCATION JainE Inland : 10510=

ELEMENTARY SCHOOL ExElic Cancel

DATES ATTENDED 182E - 192€

HIGH SCHOOL GRinG -22ER6 LESOSET.

DATES ATTENDED _ 2950 ~ 1955

COLLEGE Herdi Finone Enirerrit

DATES ATTENDED 1655 - 1950

ADDRESS

Lauross Shantarie

Chig

State

• GRADUATE?

Or are

Country

ADDRESS -

Cries

Country

CIty

- GRADUATE?

ADDRESS ATIlSIER

C125

- DEGREE

ITS 1

Country

1.1

State

-:34

COUDITY

DATES ATTENDED

1940 - 1941

_ DEGRFE

-

SEC. 13. MILITARY, NAVAL OR OTHER GOV'T SERVICE - U.S. OR FOREIGN

US

LarY

Colntry

i. Chine

Last Station

Service

415-045

Serial No.

Resign Jan E, 45 to Jure £6

Dases of Service

Honorsole

Type or Discharge

REMARKS:

SELECTIVE SERVICE BOARD NUMBER

ADDRESS

IF DEFERRED GIVE REASON .

INDICATE MENBERSHIP IN MILITARY RESERVE ORGANIZATIONS

SEC. 14

CHRONOLCGICAL HISTORY OF EMPLOYMENT FOR PAST 15 YEARS. ACCOUNT

FOR ALL. PERIODS. INCLUDE CASUAL EMPLOYMENT. INCLUDE ALSO PERIODS

OF UNEMPLOYMENT. GIVE ADDRESSES AND STATE WHAT YOU DID DURING

PERIODS OF UNEMPLOYMENT. LIST LAST POSITION FIRST.

1. FROM _ June 1946

TO -

Fresent

EMPLOYING FIRM OR AGENCY .

ADDRess ashincton, P. C.

St. & No.

CIA.

USA

City

KIND OF BUSINESS

TITLE OF JOB

state

_ NAME OF SUPERVISOR -

_ SALARY $_ 6800.

Country

_ PER SAMITE

YOUR DUTIES

REASONS FOR LEAVING

2. FROM -

Jan. 6, 1945

_ TO -

GuRE 1046

EMPLOYING FIRM OR AGENCY

U•S. Tavy

---

## Page 8

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..

-

ADDRESS

rashin-tor, 2. ca

Si. & No.

CitT

KIND OF BUSINESS

TITLE OF JOB

YOUR DUTIES

REASONS FOR LEAVING

3.

FROM JET. JEE

Honorale naschance

TO

iS. 1846

EMPLOYING FIRM OR AGENCI

== =

ADDRESS

E21ACTON.

SI & NO.

CItT

KIND OF BUSINESS

TITLE OF JOB -

YOUR DUTIES

Special scent

REASONS FOR LEAVING

4. FROM -

April 1940

TO

iano 1843

EMPLOYING FIRM OR AGENCY -

ADDRESS

St. & No.

C115

KIND OF BUSINESS

TITLE OF JOB

YOUR DUTIES

Special Stregaler desroser

REASONS FOR LEAVING

5. FROM.

TO

EMPLOYING FIRM OR AGENCY -

ADDRESS

St. & No.

CILy

KIND OF BUSINESS

TITLE OF JOB -

YOUR DUTIES

REASONS FOR LEAVING

Cousin --

NAME OF SUPERVISOR

_ SALARY E

_ PER

State

NAME OF SUPERVISOR

_ SALARY S 2AF-21 PER

Country

State

NAME OF SUPERVISOR -

_ SALARY S

GAT-L PER

Country

State

_ NAME OF SUPERVISOR

_ SALARY $.

Country

PER -

---

## Page 9

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---

## Page 10

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-

SEC: 18.

GIVE THREE NEIGHBORS AT YOUR LAST NORMAL RESIDENCE IN THE US - (Give

residence and business aädresses where possible.)

Streer End Nür.be:

CIET

1.

tro Ponald tes

Siste

BUS. ADD

RES. ADD

2505 Endeang Forster, Teres -

2.

-

BU'S. ADD.

RES. ADD.

3500 l'ademina, tourione Feues

3.

tr.

1=100e

BUS. ADD.

RES. ADD.

3E0 Mademood, FRuster Teres

SEC. 19. FINANCIAL BACKGROUND

A. ARE YOU ENTIRELY DEPENDENT ON YOUR SALARY? —

Yes

OF OTHER INCOME -

B. NAMES AND ADDRESSES OF BANKS WITH WHICH YOU HAVE ACCOUNTS -

Ferners i ercints istione

Eenise trilene, CelEs

C. HAVE YOU EVER BEEN IN, OR PETITIONED FOR, BANKRUPTCY?

1:00

GIVE PARTICULARS, INCLUDING COURT: _

_ IF NOT, STATE SOURCES

D. GIVE THREE CREDIT REFERENCES - IN THE U.S.

1. NAME

_ ADDRESS

2. NAME

- ADDRESS

3. NAME

- ADDRESS

st. & No.

st. & No.

St. & No.

CIty

Cit5

CIty

Stare

BEate

Brate

SEC. 20. RESIDENCES FOR THE PAST 15 YEARS

FROM 1936

- TO

1940

St. No.

FROM 1940

- TO

1942

Si. No.

FROM 1942

TO

1545

St. No.

FROM

1945

1947

St. No.

FROM 1947

TO

FROM _Apr 19470-

Apr 1948

Bs. No.

Sept. 1949

8z. No.

Abilene

City

Teres

State

Keshingtor,

City

Biate

San

frencisco,

oclifernic

City

Brate

Horth Chire

City

Isingtoo

Fortn

City

Celcutta

City

State

Chins

State

India

State

TSA

countrs

US.A

Countri

ESA

Coustry

Country

Country

Country

FROM -

TO

St. No.

City

Btate

Country

FROM

_ TO

SEC. 21. RESIDENCE OR TRAVEL OUTSIDE OF THE UNITED STATES

A. FROM 1920

_ то

1936

Chefco

"outh China

Cltg or Section

counin

FROM 1945

FROM

TO

TO

1949

china end India

City or Section

with parents

с Гигрове

Purpose

City or Section

Country

Purpose

9

---

## Page 11

14-00000

FROM

FROM

FROM

TO

TO

TO

10

City or Section

City or Section

City of Section

Country

Country

Country

PurpOse

Purpose

Purpose

Dir

B. LAST US. PASSPORT - NUMBER, DATE, AND PLACE OF ISSUE:

HOW MANY OTHER U.S. PASSPORTS HAVE YOU HAD?

GIVE APPROXIMATE

DATES:

PASSPORTS OF OTHER NATIONS: -

SEC. 22..

CLUBS, SOCIETiES ANd"OTHER ORGANIZATIONS

1207e

LIST

NAMES AND ADDRESSES OF ALL CLUBS, SOCIETIES, PROFESSIONAL SOCIETIES,

EMPLOYEE GROUPS, ORGANIZATIONS OF ANY KIND (INCLUDE MEMBERSHIP IN, OR SUP-

PORT OF, ANY ORGANIZATION HAVING HEADQUARTERS OR BRANCH IN A FOREIGN COUN-

TRY) TO WHICH YOU BELONG OR HAVE BELONGED: 1C

Chapter:

S4. d No.

247

DATES OF MEMBERSHIF

2.

Name and Chapter

Bt. & No,

DATES OF MEMBERSHIP:

3.

Name and Chapter

Bt. & No.

DATES OF MEMBERSHIP:

Name and Chapter

St. & No:

DATES OF MEMBERSHIP:

Name and Chapter

St. & No.

DATES OF MEMBERSHIP:

B.

Name and Chapter

St. & No.

DATES OF MEMBERSHIP:

7.

Name and ChApIer

Se. & NO.

DATES OF MEMBERSHIP:

City

City

City

CIty

- Cits

City

City

state. in

Btate

Btate

State

Beate

State

Couatry..

country

country.

Country

Country

Country

Country

".

---

## Page 12

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Bened

-

SEC'ES. GENERAL QUALIFICATIONS

A. FOREIGN LANGUAGES (STATE DEGREE OR PROFICENCY AS "SLIGHT" "FAIR" OR

"FLUENT";

LANGUAGE Chinese

LANGUAGE FrencE:

- SPEAK -

Fsi-

SPEAK

Eligint

READ

WRITE

READ

WRITE

Slight

LANGUAGE -

SPEAK

_ READ

- WRITE

B. LIST ALL SPORTS AND HOBBIES WHICH INTEREST YOU: INDICATE DEGREE OF PROFI-

CIENCY IN EACH:

Fennis, Golf, Handball - fair

C. HAVE YOU ANY QUALIFICATIONS, AS A RESULT OF TRAINING OR EXPERIENCE, WHICH

MIGHT FIT YOU FOR A PARTICULAR POSITION?

D. LIST BELOW THE NAMES OF GOVERNMENT DEPARTMENTS, AGENCIES OR OFFICES TO

WHICH YOU HAVE APPLIED FOR EMPLOYMENT SINCE 1939:

Department of Justice

CIA

E. IF, TO YOUR KNOWLEDGE, ANY OF THE ABOVE HAS CONDUCTED AN INVESTIGATION OF

YOU, INDICATE BELOW THE NAME OF THAT AGENCY AND THE APPROXIMATE DATE OF

INVESTIGATION:

FBI - 1940

11

---

## Page 13

4-00000

12

SEC. 24.

MISCELLANEOUS

A. DO YOU ADVOCATE OR HAVE YOU EVER ADVOCATED; OR ARE YOU NOW OR HAVE YOU

EVER BEEN A MEMBER OR, OP. HAVE YOU SUPPORTED ANY POLITICAL PARTY OR ORGANI-

ZATION WHICH ADVOCATES THE OVERTHROW OF OUR CONSTITUTIONAL FORM OF GOV-

ERNMENT IN THE UNITED STATES?

IF "YES"', EXPLAIN:

B. DO YOU USE, OR HAVE YOU USED, INTOXICANTS? -

EXTENT?

slignt extent

_ IF SO, TO WHAT

C. HAVE YOU EVER BEEN ARRESTED, INDICTED OR CONVICTED FOR ANY VIOLATION OF

LAW OTHER THAN A MINOR TRAFFIC VIOLATION? IF SO, STATE NAME OF COURT.

CITY, STATE, COUNTRY, NATURE OF OFFENSE AND DISPOSITION OF CASE:

D. HAVE YOU EVER BEEN COURT-MARTIALED WHILE A MEMBER OF THE ARMED FORCES?

IF ANSWER IS "YES," GIVE DETAILS BELOW:

SEC. 25. PERSON TO BE NOTIFIED IN CASE OF EMERGENCY:

NAME

Inco Fabricia do icore

_ RELATIONSHIP

2600 Feiberter Strect, Feuctor, MORES, ESA

ADDRESS

St. & No.

City

State

Nife

Country

SEC. 26.

YOU ARE INFORMED THAT THE CORRECTNESS OF ALL STATEMENTS MADE HERE-

IN WILL BE INVESTIGATED.

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 EXPLANATION? IF SO, DESCRIBE. IF NOT, AN-

SWER "NO."

---

## Page 14

14-00000

Te. Li. 1'CERTIFY THAT THE FOREGOING ANSWERS ARE TRUE AND CORPECT TO THE

BEST OF MY KNOWLEDGE AND BELIEF, AND I AGREE THAT ANY MISSTATEMENT

OR OMISSION AS TO A MATERIAL FACT WILL CONSTITUTE GROUNDS FOR IM-

MEDIATE DISMISSAL OR REJECTION OF MY APPLICATION.

SIGNED AT

FO0L20%, Resiss

Cary and Brait

Isl Puarl I Foren

Witness

_ DATE _-

i Wilter

1900

USE THE FOLLOWING PAGES FOR EXTRA DETAILS.

NUMBER ACCORDING TO THE NUMBER

OF THE QUESTION TO WHICH THEY RELATE

SIGN YOUR NAME AT THE END OF THE ADDED

MATERIAL. IF ADDITIONAL SPACE IS REQUIRED USE EXTRA PAGES THE SAME SIZE AS

THESE AND SIGN EACH SUCH PAGE.

13

U.S. GOVERNMENT PREITING OFFICE: 1950 0 - 837623

---

## Page 15

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PERSONAL HISTORY STATEMENT - (Appendix I)

Listed below are names of organizations identlied by the Attorney General, under his responsibility pursuant to

Executive Ordér 10450, dated 27 April 1953, to list the names of each foreign or domestic organization, association,

movement, group or combination of persons which he designates as Totalitarian, Fascist, Communist, or subversive,

or as having adopted or having shown a policy of advocating or approving the commission of acts of force or vio-

lence to deny others their rights under the Constitution of the United States, or as seeking to alter the form of

government of the United States by unconstitutlonal means.

Each applicant or employee and spouse (1f any) must review the following list of organizations for certification

purposes, and sign on the last page.' -üw:,

Abraham Lincoln Brigade

Abraham Lincoln School, Chicago, Illaols

Actlon Committee to Free Spain NOW

Alabama People's Educational Association (see Communlet Politi-

cal Association)

American Association for Reconstruction in Yugoslavis,

Inc.

American Branch of the Federation of Greek Maritime Unions

American Christian Nationalist Party

American Committee for European Workers' Rellet (see Boclallot

Workers Party)

American Committee for Protection of Foreign Born

American Committee for Spanish Freedom

American Committee for. the Settlement of Jews In, Birobidjan, Inc..

American Committee for Yugoslav Rellet, Inc.

American Committee to Burvey Labor Conditiona la Europe

-..

American Council for & Democratic Greece, formerly knOwn so the

Greek American Council; Greek American Committee 10r Na-

tional Unity

American Council on Soviet Relations

American Croatlan Congress

American Jewish Labor Counchl

American League Against War and Fascism

AmerIcan League for Peace and Democracy

American National Labor Party

American National Boclallst League

American Natlonal Sociallat Party

Americas Nationalist Party

American Pattlots, Inc.

AmeriCan Peace Crusade

American Peace Mobilization

American Poles for Peace

American Pollsh Labor Counchl

American Polish League

American Rescue Ship Mission (a project of the United American

Spanish Ald Committee)

American-Russian Frateraal Bociety

American Russian Institute, New York, also known as the Ameri-

can Russian Institute for Cultural Relations with the Sovlet

Unlon

americas Russian Institute, Philadelphia

American RussIan Institute of BaD Francisco

American Russian Institute of Southern Callfornia, Los Angeles

American Blay Congress

American Women for Peace

American Youth Congress

American Youth for Democracy

Armenian Progressive League of America

Associated Klans Of America

AssociAtIon of Georgia Kians

Association of German Nationals (Peichsdeutache Vereinigung)

Ausland-Organization der NSDAP, Oversess Branch of Nazl Party

Baltimoro Forum

Benjamin Davis Freedom Committee

Black Dragon Bocloty

TORM 444d UBE PREVIOUS EDITIONS

Boston School for Martist Btudies, Boston, Massachusetts

Bridges-Robertson-Bchmidt Defense Committee

Bulgarlan American People's League of the United States of

America

Callfornia Emergency Defense Committee

Calliornia Labor School, Inc., 321 Divleadero Street, San FTADClaCO,

Calliornia

Carpatho-Russlan People's Soclety

Central Councll of American Women of Croatian Descent, also

tional Council of Croatian Women

Central Japanese Association (Belkoku Chuo Nipponjin Kal)

Contral Japänese "Association of Southern Callornia

Central Organization of tbe German-American National Alllance

(Deutsche-Amertkanische Elnbeltafront)

Cervantes Frateraal Bociety

China Welfare Appeal, Inc.

Chopin Cultural Center

Citizens Committee for EBITy Bridges

Citizens Committee of the Upper West Bide (New Jork City)

Citizens Committee to Free Earl Browder

Citizens Emergency Defense Conference

Citizens Protective League

Civil Llbertles Sponsorlag Committee of Pittsburgh

Civil Rights Congress and Its amliated organizations. Including:

Civil Rights Congress for Texas

Veterans Against Discrimlastion of Civll Rights Congress of

New York

Clull Rights Congress for Texas (see Civil Rights Congress)

Columblans

Comite Coordinador Pro Republica Espanola

Comite Pxo Derechos Civiles

(See Puerto Rican Comite PTO Llbertades Clviles)

Committee for & Democratic Far Eastern Policy

Committee for Constitutlonal and Political Freedom

Committee for Natlonallst Actlon

Committee for Peace and Brotherbood Festival in Philadelphia

Committee for the Defense of the Pittsburgh 81x

Committee for the Negro in the Arts

Committee for the Protectlon of the Bill of Rights

Committee for World Youth Fliendship and Cultural Exchange

Committee to Abolish Discrimination in Maryland

(Bee Congress

Against

Discrimination;

Maryland Congress

Against Discrimination; Provisional Committee to Aboliab

Discriminatton in the State of Maryland)

Committee to Ald the Fightlag Bouth

Committee to Defend Marle Richardson

Committee to Defend the Rights and Freedom of Pittsburgh's

Political PMsoners

Committee to Upbold the Bill of Righte

Commonwealth College, Mena, Arkansas

Communist Party, U. B. A., Its subdiulsions, subsidiarles, and

attllates

- 1-

(4)

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## Page 16

14-00000

Communist Political Assoclation, its subdivisions, subsidiarles,

aöd smilates, including:

Alabama People's

Educational Assoclation

Florida Press and Educational League

Oklahoma League for Political Education

People's Educational and Press ABSOCIatIOn Of TEIRO

Virgiala League for People's Education

Congress Against Discrimination

(See Committee to Abolish Discrimination In Maryland)

Congress of American Revolutionary Wilters

Congress of American Women

Congress of the Unemplojed

Connecticut Committee to Ald Victims of the Bmith Act

• Connecticut State Youth Conference

Counchl for Jobs, Rellef and Housing

Couscll for Pan-American Democracy

Councll of Greek Americang

Council on African Afalre

Croatian Benevolent Fraternity

Dal Nippon Butoku Kal (Military Virtue Boclety of Japan of Mill.

tary Art Boclety of Japan)

Dally Worker Press Club

Daniels Defenso Committee

Dante Alighiert Soclety (between 1935 and 1940)

Dennis Defense Committee

Detrolt Jouth Assembly

East Bay Peace Committee

Elsinore Progressive League

Emergency Conference to Bave Spanish Refugees (founding body

of the North American Spanish Ald Committee)

Everybody's Committee to Outlaw War

Families of the Baltimore Smith Act Victims

Families of the Bmith Act Victiras

Federstion of Italian War Veterans in the U. 8. A., Inc. (Associs-

alone Nazionale Combattentl Italiant, Federazione degll Stati

•UnItI d'America)

Finnish-American Mutual Ald Boclety

Florida Press and Educational League (see Communist Politica)

Association)

Frederick Douglass Educational Center

Freedom Stage, Inc.

Frends of the New Germany (Freunde des Neuen Deutschlands)

Ftlends of the Soviet Unlon

Garibaldi American Fraternal Soclety

George Washington Carver School, New York Clty

German-American Bund (Amerikadeutscher Volksbund)

German-American Republican League

German-American

Vocational League (Deutsche-Amerikantsche

Beruisgemelnschaft)

Guardian Club

Harlem Trade Unton Council

Hawall Clull Ilberties Committee

Helmusha Bal, also known as Nokubel Helek! Gimusha Kal, Zaibel

Nbonjin, Helyaku Glmusha Kal, and Zalbel Helmausba -Ka1 (JAp-

anese Residing in America Milltary Conscripts Assoclation)

Hellenic-American Brotherhood

Htnode Kal (Imperlal Japanese Reservists)

Finomaru Kal (Rising Sun Flag Society — & group of Japadese

War Veterans)

Hokubel Zaigo Shoke Dan (North American Reserve Oficers Asso-

clation)

Hollywood Wrlters Mobilization for Defense

Hungarian-American Council for Democracy

Hungarian Brotherbood

Idabo Pension Unlon

Independent Party (Seattle, Washlagton)

(see Independent People's Party)

Independent People's Party

(see ladependent Party)

Industrial Workers of the World

Internatlonal Labor Defense

Internatlona! Workers Order, its subdivisions, rubsldiarles and

amiliates

Japanese Association of America

Japanese Overseas Central Soclety (Kalgal Dobo Chuo Kal)

Japanese Overseas Convention, Tobyo, Japan, 1940

Japanese Protective Assoclation (Recrultlag OrganIzation)

Jefferson School of Social Sclence, New York City

Jewish Culture Soclety

Jewish People's Committee

Jewish People's Fraternal Order

Jlkyoku Inkal (Tbe Committee for the Crists)

Johnson-Forest Group

(see Johnsonites)

Johnsonites

(See Johnson-Forest Group)

Joint Antl-Fascist Refugee Committee

Joint Council of Progressive Italian-Americans, Inc.

Joseph Wedemeyer School of Social Sclence, Bt. Louis, Missouri

Kibel Beinen Kal (Association of U. B. Citizens of Japanese An-

cestry who have returned to America after studylog la Japan)

Knights of the White Camellia

Ku Klux Klan

Kyllhaeuser,

BISO KDOWn so Byllhaeuser League (Kydhaeuser

Bund), Bythseuser Fellowship (Kyfthaeuser Kameradschast)

Kyllhaeuser War Reliel (Kyihaeuser KMegshulfswerk)

Labor Council for Negro Rigbts

Labor Research Association, Inc.

Labor Youth League

League for Common Sense

League of American Wrtters

Lictor Soclety (Italian Black Bbirts)

Macedonian-American People's Leaguo

Mario Morgantini Circle

Maritime Labor Committee to Defend Al LANDOn

Maryland Congress Agalnst Discrimination

(See Committee to Abolish Discrimination in Maryland)

Massachusetts Committee for the Bill of Rigbte

Massachusetts Minute Women for Peace (not connected with the

Minute Women of the U. 8. A., Inc.)

Maurice Braverman Defense Committee

Michigan Clull Rights Federation

Michigan Council for Peace

Michigan School of Social Science

Nanks Telkoku Gunyudan (Imperial Military Friends Group or

Southern Callfornia

War Veterans)

National Association of Mexican Americans (also knOwn as Asocla-

cion Naclonal Mexico-Americane)

National Blue Star Motbers of America (not to be confused with

the Blue Star Mothers of America. organized in February 1942)

National Committee for Freedom of the Press

National Committee for the Defense of Political Prisoners

National Committee to Win Amnesty for Smith Act Victims

Natlonal Committee to Win the Peace

Natlonal Conference on American Policy in China and the Far East

(8 Conference called by the Committee for a Democratic Par

Eastern Polley)

National Council of Americans of Croatian Descent

National Councll of American-Soviet Friendabip

National Federation for Constitutlonal Libertles

Natlonal Labor Conference for Peace

National Negro Congress

National Negro Labor Council

Nationalist Action League

- 2 -

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## Page 17

Nationalist Party of Puerto Rico

Nature Friends of America (since 1935)

Negro Labor, Victory Committee

New Committee for Publications

Nichibel Kogyo Kaisha (The Great Fujul Theatre)

North American Committee to Ald Spanish Democracy

North American Spanish Aid Committee

North Philadelphia Forum

Northwest Japanese Associatlon

Oblo School of Soclal Sciences

klahoma Committee to Defend Polltical Prisoner

Klahoma League for Political Education (see Communist Politi

cal Assoclation)

Original Southern Klans, Incorporated

Pacide Northwest Labor School, Seattle, Washington

Palo Alto Peace Club

Partido del Pueblo of Panama (operatiog In the Canal 2040)

Peace Information Center

Peace Movement of Ethiopla

People's Drama, Inc.

People's Educational and Press Assoclation of TexAs (Bes CommaU-

nist Political Association)

People's Educational Assoclatlon (lacorporated under name Los

Angeles Educational Association, Inc.), also known as Poople's

Educational Center, People's University, People's School

People's Institute of Applied Religion

Peoples PrOgrams (Seattle, Washington)

People's Radio Foundation, Inc.

People's Rights Party

Philadelphia Labor Committee for Negro Rights

Philadelphia School of Soctal Science and Art

Photo League (New York City)

Pittsburgh Arta Club

Political Prisonerg' Welfare Committee

Polonla, Soclety of the IWO

man-Americans of Chicago

Proletarian Party of America

Protestant War Veterans of the United States, Inc.

Provisional Committee Of Citizens for Peace, Southwest Area

Provisional Committee on Latin American Afairs

Provisional Committee to Abolish Discrimination In the Stato of

Maryland

(See Committee to Abolish Discrimination in Maryland)

Puerto Rican Comite Pro Libertades Civlles (CLC)

(Bee Comite Pro Derechos Civiles)

Puertortiquenos Unidos (Puerto Ricans United)

Quad City Committee for Peace

Queensbridge Tenants League

Revoluttonary Workers League

Romanian-American Fraternal Soclety

Russian American Society, Inc.

Bakurs Bal (Patrlotie Soclety, of Cherry Assoclation - composed

of veterans of Russo-Japanese War)

Samuel Adams Bchool, Boston, Massachusetta

Santa Barbara Peace Forum

Bchappes Defense Committee

Bchnelderman-Darcy Defense Committee

School of Jewls Studles, New York City

Seattle Labor School, Seattle, Washington

Berblan-American Fraternal Society

Serbian Vidordan Council

Bbinto Temples (Iralted to State Shinto abolisbed ln 1945)

Silver Shirt Legion of America

Slavic Counch of Southern California

Slovak Workers Soclety

Blovenian-American National Council

Socialist Workers Party, Including American Committee for Euro-

pean Workers' Reiler

Sokoku Kal (Fatherland Soclety)

Bouthern Negro Youth Congress

Sulko Sha (Reserve Officers Association, Los Angeles)

Syracuse Women for Peace

Tom Paine School Of Soclal Sclence, Pblladelphia, Pennsylvania

Tom Palse School of Westchester, New York

Trade Union Committee for Peace

(See Trade Unlonists for Peace)

Trade Unionists for Peace

(See Trade Unionists for Peace)

IT-State Negro Trade Unlon Counchl

Ukrainian-American Fraternal Unlon

Union of American Croatians

Union of New York Veterans

United American Spanish Ald Committee

United Committee of Jewish Socletles and Landsmanschaft Fed-

erations, also known as Coordination Committee of Jewlah

Landsmanscharten and Fraternal Organizations

United Committee of Bouth Blavic Americans

United Defense Councll of Southern Callfornis

United Harlem Tenants and Consumers Organization

United May Day Committee

United Negro and Allied Veterans of America

Veterans Agalnst Discrimination of Clull Rights Congress of New

York (see Civll Rights Congresa)

Veterans of the Abraham Lincoln Brigade

Virginla. League for Peopie's Educatlon (see Communist Politica)

Association)

Voice of Freedom Committee

Walt Whltman School of Social Sclence, Newark, New Jersey

Washlagton Bookshop Association

- 3-

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## Page 18

CERTIFICATION

I certify that I have read the names of the above listed organizations.

To the best of my knowiedge and bellef, I am not, nor have I been a member of, contributed to, received liter-

ature from, signed petitions of or in behalf of, or attended meetings of any organization listed above, or any

organization outside the United States espousing Communist, Fascist, Totalitarian or Nazi causes, except as noted

l'o the best of my knowledge and beliet, none of my close relatives are, nor have ever been members of, con-

tributed to, received literature from, signed petitions of or in behalf of, or attended meetings of any such organiza-

tions, except as noted below. menc

INSTRUCTIONS

For the purpose of this certification, i an applicant or employee is completing this form, the term "close rela-

tive" will include spouse, children, parents, brothers, sisters, uncles, and aunts. "Close relatives" of the spouse, for

this purpose, will include children, parents, brothers, sisters, uncles, and aunts.

If there are exceptions to this certification, set forth below under Remarks all pertinent information concern-

ing the nature and extent of your activities or those of your close relatives in such organizations, including the

names of the organizations, dates of membership, meetings attended, titles of positions held, amounts and dates

of contributions, nature of petitions signed falling within the meaning of the above certification and circumstances

thereol, titles and authors of literature received, and dates on which received.

In exceptions concerning relatives, include only such information presently known to you or available from

If necessary, use additional sheets and sign each sheet. Write none it there ate no exceptions.

REMARKS: To be completed by Spouse

REMARKS: To be completed by Applicant or Employee

- say w. .

Date

Signature of Spouse

Fatricia. Ci Mere-

ddress - City and Stat

5145 festin Lane, Data Le

Witness

Arth Strationn

Address — City and State

1413 Coquins, Getand, Lear

Date

Signature of Applicant or Employee

Divinitin Miran

Ada sisten, Deins, Leas

Witness

Zith, Barkam

Address —City and State

1613 Beenis, Titand 2pas

-4-

tast

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