RECEIPT FOR IDENTIFICATION CREDENTIAL.
Agency: CIA
Originator: CIA
Document date: 01/01/0000
Document type: PAPER-TEXTUAL DOCUMENT

## Page 1

104-10121-10205]

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RECEIPT

I,

, have read the above

provisions and completely understand the responsibilities placed

upon me in accepting CIA Contact Identification Credential No.1716

(Signature of Recipient)

NOTE:

This form will be executed immediately and forwarded to the

Central Intelligence Agency, Attention: Director of

Security.

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