## Page 1

€ ON

(SPARET.

completed,

"BASIC SOURCE DATA/ISR REGISTRATION OR NAME PRAES

RÉQUEST

Routine

PrIOrItY XXX

UCHECK

REQUEST

RIORIT

REQUEST ISR RESULTS ONLY BY COB 24 Mar 1972

PART I

(Specify type of request, e.g., ISR Registration or Name Trace.

NOTE:

If ISR Registration is specified, Name Trace need not

be. ISR processing automatically includes name tracing.)

File Number

238852

Date

17 Mar 1972

Unit Designation_

_ 242

Project Number_ 1201-02

1. a. TRUE NAME: WERBELL, Mitchell Livingston III

TELEGRAPHIC CODE:

b. ALIASES:

C. NEE OR DIVORCED NAME:

N/A

Postponement

-

Section 6(3)

2. DATE OF BIRTH:

3. PLACE OF BIRTH:

.4. SEX: Male

5. CITIZENSHIP: a. Present Uas._

b. Previous.

6. NATIONALITY:

U.S.

7. SOCIAL SECURITY NO:

Unk.

8.

PRESENT RESIDENCE:

9. PERMANENT RESIDENCE:

EL'

• -USAFAC FOrm 1

Same as Item 8.

24:4

TIAT

• (SECRET

when completed)

DOD DIR 5200.10

USATAC 1904/12-

NW 55538 DocId: 32108743 Page 1

---

## Page 2

CON-E

(SECRET

HIKT

E

completed,

10.

PAST RESIDENCES:

Un SECRET

11. OCCUPATION: President

12.

PRESENT EMPLOYMENT: Defense Systems Inc.. Powder Springs, Ca.

13. PAST EMPLOYMENT:

Rich's Department Store, Atlanta, Ca.:

Werbell, Seklemian and North Advertising

Agency, Atlanta, Ga.

14. RECORD OF MILITARY SERVICE: OSS Officer (CPT). China-Burma-

India Theater of Operations, WWII.

15. TRAVEL TO AND FROM THE UNITED STATES:

a. Passport or Alien Registration Number:

b. Date and port of entry:

c. Mode of travel:

16. AGENCIES CHECKED IN FIELD:

IRR dospier recalled 17 Mar 1972

17. REASON FOR TRACE: S/A

UCHECK

REMARKS: Request all checks, to include Lor, be expedited as

much as possible.

F. H. DILLON, JI.

Colonel, MI

Commanding

24-6

"FETCH COMERAL

DECLASSIFICATION SCHOULE

DElmpleted)

NW 55538 DocId: 32108743 Page 2

---