ML19053A689

From kanterella
Revision as of 17:52, 14 March 2019 by StriderTol (talk | contribs) (Created page by program invented by StriderTol)
(diff) ← Older revision | Latest revision (diff) | Newer revision → (diff)
Jump to navigation Jump to search
NRC-2018-000725 - Resp 1 - Final, Agency Records Subject to the Request Are Enclosed
ML19053A689
Person / Time
Issue date: 02/15/2019
From:
NRC/OCIO
To:
References
FOIA, NRC-2018-000725
Download: ML19053A689 (12)
v • d • e


Text

  • *l'I
  • I -' ' ..... NAY l O 1976 . '
  • l *
  • Longview.

Washington Menial John Patton I I I ! I I l I I I. i ! I ! ft I 11 j ,, it l F; 1r>-fftf*AWV£S llwlnl,, ,t,p~r,11~0,~, l><I"'* *~ dJoor<<d *P.Ot.itt ot =.If! * . ,,.,,,.., l:'J.Ml'IMizlil, aM mo "'11,/tiut, IWbil or deDIL Niiht.e I.P')IJU C'i'4 oil<< Off" Y6U 1/Jan)' *o&*eqrttllt to Ulr ~II, of tl&fa !lUtSfkiWJll't.

it 1111/I bl tu rtn, rotMra, ftaUr<<. "~fbrorMtt, 1/Jlp,lsl#rl, h4Jf_ bl'OUler., m~t.\tf 11\VIIIU f pnt,Jot,.1*

mtJrrilzke.

ml' t, 1"""poua

  • fur,wlt,d, 0)¥ Form ;;t 0354.) l . .: ., -: ..... I -:-~~ Na .. 1tahll ,.,. "'"'"' C6Q1IU)I o( *~ *-e~-Father Charles frank Bazata. v 100 Dead USA USA Mother Alma A1y1ettnger Bazata 92 Pres. Home.Car11s1
  • PA.USA USA Wffe 35 Marte p erre sencmuter

,__ RT2,Bx97,.01ckerso , MO II E FRENCH Fath.-1 -Lav Noel Senequ1er-zet 65 Papeterie de la Go t Mo .-in-Law Domenetzere, Fran Dead' . e FRAN E FRENCH Marte-Magde1efne Sap~ s.-c. . 'Brother Charles Frank Baz~ v* 68 . M1aa1, Florida USA USA S1ster Beatrice Brown {)J.~ 67 Dead USA USA Ex Wf.fe Diana _Ch.trl~fson~ata . ' 5101 Rfver Rd. Ex Wffe * (b) (6) rf',

  • Chevy
  • Chase. MD Sfctly USA Penelope . Grant, Bazata *. ? London, England Australt Brftfsh. (fult~t-knovn) (Dates and laces for 111rrfages and divorces tsted.on reverse si e) l&. REJ,'E~C~.(Nomt

'thlW./'RfOII.'*

Ni>t Ref#~'vtt tJr Employer,, Whl> I.re. Wfll A.c,q~tai Wit,\ 'ri>tJ), . . ... Reference list attached.

CB8.'t1flCA2'ION I Aou, ~.OU .o/tM obow qumton., lt1rtrti 1M lltf61'111r,t/qt,;fwt,l,Md " 071,!1111r ro* thu1.qli#llons II Nrrecl Md to/rlfl(M.to tA~ &!it of Ill.)' l<MJwlrdg1 (Ill(.( "'~ On4 *l Ptldtntontl lAal i'r fa of gttllf lmpOTVM~I

'111 IM. e'>lll'"r(/.twA 6/ 111).' .t/glbl/l.ty to, lfflJriJy

~-ot ~,. o.uuiorkfl.llo11.

{ mtrl<* t/Jb ,tti<<ffWII to w V: s.,~, BMro Collllllls*li>il IOilA dlt un1UtWWllnl/

111111 il ll'lll. o,. IU<<l 6Jt a,.,. COJM1ledo11111 fO,,Y~ o(I( ltA du{Y ro protttt 111,.,e~~

ofthl.albml#_,rurgyp~J,ct.

ofld.fllllh l<1101D~f thl oro1t16slonofmourlol

/od f110:Y o, 111(/t,eltfll C<1,u,t.(;;, r,Jeclk,n 0/ 1>>.)' .oppl/l:OWfl.

or' dlt'11fnol.

o(ltr fftl/Jl.o.)'rMf/1; I~ t/,al, aAj, /a/41114ltmtnl littt!A 1110,, b, f'Ul'..blltd.

o, a 1,ton.y IPldtl' Sffl/o11 lo~!* 'l'ilU llJ, V, . $:-Cof-, _ . , , , , , . * , 'l'o ~s ~tLt.EDOU.'r ar*AotNCY 01u*11tM EM)'lOYINCI , , ,. I I ti ( I -I But1dtn~1M.aoagement S~1a16st . .. . ' '* US rluclear Re lator.y C011111fstfo11 It ADDRESS Washington, o. c. 20555 WU,l, PBRSON ffAVJ: ACX:ESS TO: iiESflUCl'EDDA'l'A

'(41 0 No 0 ...........

X ~XCZ.l!SJON AlEA Yu O No 0 FOPS4 ..... I I f ' ' ' i I I I . I' i

  • 11 I I I I 'l I Ii I I

.. 115 It ,. ... .. -*, ' .. .. I *r

  • f ** r ' I* I "'t 'I ., .,. ' ...... 1-Ll!AWJ)..>>ctoxo J.&~ n1, $Wt: (l) ~* u4 .BMt ... ~0111, l'f.Jlff,*

(3) ltfflm~* Or4e.r ot ~tea (l."' OXle ~t Slcle (Oli~) to 'bf co,, ..ltevtm ~<<* Mt0a ctci.) ., *' Marrfed Qfana. C,*Baza~-Newark, HJ 1942 or 1943<, * *. * 'IJ.L.*. *, .. * .. *!

  • f: Divorced * * * '.
  • 1fashtngton.

D.c. 1945. 6t or 7 Married Penelope G.

  • Bazata-.London, England 1/5/48 .. . . Divorced
  • Kens1ngton, London,.England (Applted.1/15/52 and . . I * * , ;41vorc.e
  1. 1740 was granted 2/,27/!2) Mlrrfed Marje P. Senequter--

Attbe$, f'rance 5/10/70 I .. '!* ... 4-, ... ** ' I* ' * ,; .. I l,t..; . . .. I *~ ' '. t j, .. I ,, *I l. ' I : J ,.,,,, . r I* 1. I I .... J .. ' . ' ,. . ,, : ,')h ,., . t ., ' ., 1"'"*. . I t1* * *, ,qJ,'. .. '. ' I ,, .:.: f r* . .,,-.. ,, .. ,l .. , ,, .. ...,. . ' r ,* *. * . . , *'],.! If . H ~* .,. 4. I ,., I ,I ... , '~ l. -~ ,*! \ t.J.\ ,.! .:: \ J..l ** ,, . ' ! . *r ... I* .,;j t, . I .. ;-. l, t; .. .. *11,; . t**. . . :. ' I . .. I.. I , . .. .....

  • I. :~ .r I I . , .. **, ¥\ , !.,
  • 1 i( ,;I '* . .... .. ** . .. *t**,. ' I *I"' ,,, ' *.l 4J ** I ... , ...... ., .,,, I I I I .. I ! \' 1 I.

, ~TOMIC eNERGY COMMISSION , WASAINGTON, D,C, J0$4$

  • L SECURITY' QUESflONN B. U yov, on,wer ro A It "YH'!, 414 yov, dwlt19 the petfo4 of ,..,c1' r,,,~1,,h~

or ouoclotlon, h1N* tho 1pecltlc lnl*nt to fyrth,, I, YCJES tt.e 01111 of *~h or9011borlon or q,ovp of p,r,011, to ov,,,htow or onrt11t" "th* GoveJDtMtlf of ,,.. U11lt*)f $tot* or fl'IY p01itlcol 11/Wlvl1I011 thett~f l>y fore,, vlol111C*, or V11lowf11t aeon,t * . * .* 6, If )'9111 <J111wer toOuHt/0111

,. o, 5o, .ohv* 1, ':¥**", 11010 l>elow, vMer "'"' No, 11, or OIi o 1oporote th!** ro h ottoc~d *o ond tt1o4o o port of thl, ~ttlonnolr*, the 110111n of oll ,111ch oroo11l1otlo11*

4,,.1 dot .. of ,.,,1111>,11Mp, Gin cOMpl,M d,tolh of yOVt ~etlvlllu 1h .. 1l11*~"'°"'

""1 *111plot1otlon you d11lr1 t19<<dl110

>'°"' t111ml>er1lilp or octlvltlu, ME ADDRESS l"ROM TO Of'f'IC "EL.O 7, *ORGANIZATION MeMSERSHIP (lnclll4*

oll pre .. 111 -.um~*rshlp oll po1t 111e111 era Ip 111ln9""t

  • lost 10 y1or1 In oll oroo11botlont (txcopt o or v11lo,ia olld relloloc,a oroo11l1otlon1) nol cove,1d b Qu .. 110111 5, ond 6, obove,) ' $. Hov* yo11 ever be*11 orr**t*d, ct.oro*4, Of lioW l>y Fe<l,rot.

Sto1e, 0,1,,, low ,11force10er1t O',/lhQrltiH f<< 011y vlolatloa ol otay f*derol low, $tot, faw, c.0111117 or 11>unlclpol low, requlotlon, .Of ordllionce?

  • oo i1otf11clvtfe Oll)'thl"9 thot hom111d l>1f9t9 yo11r l6tl, bhtt.40)', Oo 1101 lnclll4* traffic vSolotlone lot wlll~I, o fin, .of $30.00 Ins wo*. l111po,..t, All oth*r ~h0<9n 1a11a1 .t.* lnClll4ech;v.t1 If th.r WefO 4lt1111H04, I . I f I I tryov* anawlll' ls "Y**"* c:0111Plot1 all c<'l1tl**

lfl ltt<&t, ~*low, YES~ Cll'\' I 9, ARRE$T$ (Co~pleto A,B,C, ori4 0 for ,act. co11, IMle1d* oll otr11tr~ f1,,.,, oth,, th011'"'l110, lrof£1c vlolotloi,1 evtt1 If the chor;u w*ro dl1111fu1d,)

A. OAT£ s. C.HAROIB.

  • PU I w ~E sr AN N * D, ACTlON TAKEN ~"~'"'

,*, *~'" .. -:t *' (OATC .ANO ~I.ACC WHUC $IGNlO) .1N$YAl,ICTION$

'YO APPC,ICANT UPON COMP&,ETiON OF ABOVE a Now rhot rhe for,r, 'JI tlt11td, ploc* It ht th* pro,oddreo*d "IVtlop* fe1rra;,h,<I, ilo" ocrou ,r.. envelope flc,p on the lltae provU,d, and offhc rhe .cfot* of 1lono111r1, O*nv,, thl.,*ol*d

  • 11v1tope to yo11r t~lorer 'i1a111t,ll<1ttlr 1t1oll dlr,ct to th, oddren***
  • , ' -=----------~------------------------------------..---F.bPS6:----------'

'* '. ., .

PLEi\$l .. 'Before Mokl119 011y etltrlH Oft thlt 1lclt1 (I) ~.111ov* ~d rever,, co,bo,1 p~f, (2) Rev.r** l'h* o,der of copl** (l,e, copy Ofl* lro111 side (oritlfiol) ro be copy or,e ,enrH *14* olso, etc,) *

  • 11, AtlOITIOtjAI.

$PACC f"OA f>~IUIISJ.ilNC IN ,oAMATION IN ITCMS ,. TO 10, .(hldleo**

lttll\ fl\llllbtn ro ..... ,c .. Oftlwer* opply,) ITEM NO, /tJ IJ /(/, ./5 ... .. . ' 6)SS--OCh<;c t:Jr *.s-';-.RIJ. 725 .c(/ c' t:}C/ /f'JL.3 -7?-~<<_ /?yv-. :Sc12i/1 C5/' -L/-7~ -cY/?A.J/tf! (b) (6) *-y$,=e;r; t7/J/ #'~. ~J: l?):;,4/ ,# // ;1!"/ . . , . .. " I * *' -1, ' .. ' :, __ .:i.,. * ., ---._ .. _........

  • -.. **--*'. '"-' . , ... FP0.87"' . .. .. . * '"' r' I I I [ ! i I I I I ! I I K l I I i i
  • ,e-i -:.t * .. ' * .. . * * .. . . . . , ...
  • Douglas Oel.Jitt Bazata. } ,/ j'-1. DavhLfegan(Ernerson (b) (6) ) (b) (6) ' J,. Prof. Alan Haemer ((b)(6) V (b) (6) * ., . REFERENCE LIST ,,. * ) . * £. Frederick

& Harriet Wildman ((b) (6) ) Occupation*

Wine Importer v--<b)(6)

  • ~4. Paul Cyr(Might work for FEA, Wash. D.C.)
  • Business phone in ~Wash., D. c. area-961-8637 . Is. Robert VanRoUen ((b) (6) ) I . (b) (6) . 6. Col. William Pietsch ((b)(6) ) (b) (6) . . J'. Hon. wn liam E. Colby (b) (6) . ("' / s. Col
  • Lu~i en E.
  • Cone! ein (:(b) (6) ) V' (b) (6)
  • r1' t-. t . Business phone with DEA, WDC-382-8825 )* Glen Wolfe ((b) (6) '> . (b) (6) L. Frederick Schwartz (Plaza (b) (6) ~IIJ, (b) (6) . . J 1
  • Or. Bernard Knox ( (b) (6) ) Director of.Hellenic Affairs (b) (6) ., FbP.s.a* .. ., . . ., .. ... . ... ,I ,I, ,,, . ,'

.... ..... ., . . , . -~, Dougla~ DeWitt Bazata REFEIRENCE llST (Continued)

  • 12. Hon * .Phi111p Chadbourn
  • Chief of Propaganda and Protocal (b) (6) 0~1a. Dr. Albert Rohan (Austrian citizen) '(,P/ c/o Austrian State Department
  • /' Vienna, Austria
  • 14. Edwinston Robbins and/or his wife (Phone #(b} (6) ) (b}(6) ,. I -' . .. .. ... (Robbins also has a* residence somewhere in Pe~nsylvania-Phone. #Lawrence (b) (6) ) 15. Baron Hans-Georg VonStudnitz

~i, (b)(6) ~,. . ~* Baroness Madelein VonMunm (b) (6) . -or-. *(b) (6) 17. Jeoffrey Ha11owes (b) (6) ORGANIZATIONAL MEMBERSHIP (b) (6) FPDS9 T I ... '

c/'l't5tpa;-:t:',e-

~/tdU/ * . ~ISL: /JA/PtfG ~* , -C S4;p.~V ~/JM' /3 , 414 p$GL6/!ve u!ut . . ' e 13;£~/Y<J . 'J:; ~#A/C/< 6 -.. .. I -" a. :. I;. "'tit.. ,. .. , .. :.: '-.. : * * * ~* ~. _ ... ' II *"* .. :. ., ........ .6t .. ,,.. ** 1IJI' 1* ............

-:,,*11 ..., ........ ,.::;a.,.;*

1 .--***.,, d, , : .a , II *."', *'1**~ "'9 1 ,,r ""'*** :~; IF A";.1£tl.

mo,c:A'tl?. , .. , *-~, '.: AL\*11 R8G)$'tllATSOM a;o. ,',,;* *,, ** ,~,* I :.2*~'. 47/.;

  • 0 *.:-1 ,1 ..

, * * ~\e "-"'i_~e\e

,$VY-' ~)! .. "' , t l * ~o . ~\e' ~e(
* ** { -. * . e'!t~

~e,i \ . . .. * . --ifn.\o~ A~~J u<A~*1 h ~0":, C ,\'iOM 16 ENERGY CO.MMISSION , * .}'ol'II)

Af>ptovfd ) {~~?~t;i ~.r.Ja,~ J'o?i.\ t$'i>'O".,.i\~~

0 Wa,hinston, D. C. 20545 . ' ..O.M,~. *s .. yoJts 1 !A;:,tQVA$.~I;~iA*{*

1:" 3 C:~\u~ PERSONNJ~L si,;CURITY QU~TlONNAIRE

' . f INSTK'vC'rl,.0."18

.!., J"A'Ud AEC.l HM 1WO .PARn. ,.U,l,. SEC'l'IONS 0}' IJOT/t PARTS >!UST IIC COMPLET&D.

UN£ESS 80'/'JI l'/1.R'/'$

..tR~ COM/'/,E'rJ:J.,Y AND "f'ROPERL'I EXECU'l'F.'D. "l'IIB FORM WILT, NOf' 1Jl! ACCE'P'rl:D.

Uort: Ofl¥ ~,;:r/£1 llt'f wwJr, /amlZ/;lr¥.~

~o'11r. ,,._ , U1/ l",rl.\ oil q*ta:i<,11*, Do ROt ~" lDIIJ~u.t

{Int nodlttg t.hf t,utru.~,u an4 ~tfff/lcotlo11 o.c rt..d o/lM/orm.

'l'fPI: OR l>IUN'l' ALL /f.NSWER.$. , I 1/ ftll>rt *pqc, iJI nq<dr~ rnttr us ~,,. 11 ois &ot.4: c,/ "'1* /or-m a, ,atv.,,;t,.

o4d,'tJ.o,u,1.

,,-~~* o.nt/. /Jadkote d.e 11.tM 11cm11hn Jo 111hkla tlH ans111cr*'

  • , apply, Q-.k1ttons rtJAkli d~ rw,t Of>ply 1liould bUMrkrd "No11t*, * * , nA.MI:: (IAJf,. 1-V*r. MltJJ/.~)

4, Dt:l:ICltll"llON

/ ?ltlZ,9 Tli JrJu<l4s .:)d Id r T t AloL Offl£R-NAMES (i !!, 1N1IIJ,11 nom,, 110mt1 i>:, /otmfr $. S CJAL SECUJllT'X'

  • *o. 1 Yter 111arrlotfl, an4 U-.ot 11 , wernfed) (b) (6) DA TE !2LL. f ,.A-' 0./'/ JC-7, S RTHl'LACE (C'.Jt, CormQt, Swtr, oM. CIJu.tJJ~J * . /?~l'l;;WT,f ;.r::..-YA/~

.?Z,.5;AJ, S. l\lt an *x.

  • la Ap,propJl.aW BQJt; J,--ttu:stN:'

RESJDS:tCJ::

($t1ttf ond. Numfm. DAJE ' Stos>t O M.irled WlcSow(tf) 0 Dlvomll (J * ~'$wl81.atc)O~.,!}

l~O.l!T h',~L. I 7 :1. " .. * *.l! r. -ax. 9* ':J '/ (Datt & Platt cf lJll/¢r<<(I}

~"RS,(!,'v*-

  1. .t ... 'ul U.:1 .... . -~. ALX. OJ{& nESll>ENCES

.10.R 'l'AST 1, Y&\RS DATES t~ CITIZENSHIP; U.S.~ .Aile~ 0 2c~ 7 1', rl'J,t'-'11/

Sr. t'l/l~;'/,,/t" ~I 4/ --A.lfU,S.CAtl%Co.bdleato,11.tU-.tr. , : ~.A .2. .2.2. 0 *7 -{/-7 .l.. 7 S cu Sy ~lrt!l (3Hly Natllr*?l7.atlo1' n , "'/-/;L,.~tfe r 4'4'$11' -/_ ,'J IV)., V%f 4'.I~-(2) j)t1lv*t1ve a: A!S.to. Rtg1.U&UoQ No. * /-:!'{)/.

-l-£.z:/vY//?

/')~~t,* /. .. ')/-)& .. ,')

  • r S,1.,;f!~,v'-

t/.1':ti;-71,'/p'n

% 4# B. Date ~Q No. ! /Pf!! L:; ~~J!/Jy .. {'1,-:/-/e~, /;(Q,-~J("J/.

Cc1\ltlcatlo!llN~

Date * ' t<-1'2G.sj1#~1?"~

S.3/ 7 ;.:?~£~)" ~. ... . n." * * * . :~~n~o. 4'1 i'l '// "l\-, \ /-;)/--.... 7 /~ * . . ... .,, . .,, ~v .. . .. -* 1.e:--V-. ./} 7.' ~6 S' e1 J!.' VI"~£/'_~?

,1 t,~

  • s. u alle~ ladJc;,.ie:
  • ..,. .. tF-hl """ or &<nptoyn .,c..,.,,,y., (),j ...... 1 ** , /t'r~~ 7.., ... 1:.,7 *r. /~r~H ~o ~;,,,.-*:,.,17il/2P r/J,,R//J

' {(2) l'.mcr.t Cidui:iallJ,p

{3)Dt.tiofEii~----

rfr~oi ~tr)" "-'S)ptOCWf~

1IU,Pll'Nil0l't N*ll'lt '1~1 h,;;:!tt/()1}>

P}) *, :J;'J_p.:!'/2 .J'/?fi; Jv ~'!. ,1-10, . ~d#.1!11.t.

tzi'nt# ~77&1V, ... ~.-191/,-J

~e.L.,f"-Ji-e~.-A/.gu~r,;h/__._

c: //.i~/c.-: 19-;r 1'1/~#£;J~} -/ 9 4'8 ',?1t.Lr114l O/Y44~1~ 7¢&U-"7~1'~-

~111/,-7 . ~1.;.. r: * * * * --,J ,I l'L .,u:"t,,~ ,v t" 2..-~)-,.AJ,".t.~

r.,p.,e~-4-/Z,?/ V ~W/t(Jr£ * .,,.,1:-...,r

~.#"h. It,'#. A*U4.I. I:,*-~? OS'S .:.. /~C. ;.J -..r-~'i,:.., , ~,,:,,~7',1;!;,'4'14/

u, 11.;,.G. ~7/.t ,; -38 l:l~,N~ &'6"-C'. Cc' )eJ'Rfn'T e1/JC,bS.

.. /#.#//. -I

  • 1'?2'/r~;7"i"~N , -<< * .
  • 2>. C, . :SM~i ~c . ~. / :-3 7 .. J3/J.C /2/f',4/C H , *hSlt/~'l}./'T~-

~~y~*. /2/}/./C/lae

/?1£./~~G.M.

i:.:}i)' a~ ;?J/}-/'JWd_

"*'pVl ~5-T~v~.tf:.#;'.,~/,&~

///72:~L.., !L, ,l'if/l# ~11"7( . u-Q,:;-1/,1";,,";),~

.,-~v;;;-a,,.u, '/)..jj, r'A74-'"ll/,fh'

" ' ' Wc.,+'r'~ .il,e.e -;,J,,,'e,//

4~~-FDPffl1 ** I I . .* -.---" ______ _,__ __ ll, )'01':tlON' COUNT:tlF.$

VISIUI> (B~cl111l,*t

~/ NIJl/4,y &rukt <md. U,$. Cqvtrnm.t~

0//lcl#f ;;(,r,d)

  • j"-*-_.. ** I I .J'4 * \ * ... *" * ..,..., ...... _ .. ,,__.~ ...........

l ,.., I "'~" .. .. * '""""""" I I l'a*l .... l' 4 ....._,._

.""1N .. *t'IA,1 .. I I I t ! I ! ! I i I I I I I i I g t I I I ! I i I I [ I ! i I I I I I I I I I I I

_:1, .. * ** 1, **-/ .. .. "' . .. , . ** * .., .. * * .. 4 * . .. -" of, . .. .... ' . * .:,11. f f ,. * .. * .. , .. -. . . "*'-'* *ASS -B,fo,, flltlcl~ Ofl)' ,..i;, .. OIi Ž* 114,1 (I) R, .. ov, on.d ffYlfH* co,\,(,ft ,o~,. (~) Rneot tt.o "OI,., of (O~: .. ca *** co,, °"' '*~* tl4e (orioiMI) to h copy 911* nvtrtt sld, ol~o, ttc:,, ' ' 4 *, .. .... 'I ., *, ,-i:* . . . ' . " * '.* ... " !. .7. ,~,~ . . .. *' . ' I . ~. \. , .........

..... . .. ... .. " *, .. ,. L#Te (b} (6) ~/!freP~/t/ :l)cJ/t1~t/

~/V .... .. -I' _. I t I I I I *---. . .... *'" ., ,, ti . r . : '

  • 1 * : : ., ~** ___ _ *. I ,, . . ' . . * .. ~) I I .. . ** .. * . ~t:7: /9¥LJ> . /?#.r-:-.

... , .. ... .. ' I I !..__ __ .. I I ", \' * ** > .. . ,: ... .... ' . .. . .. ,);;,..e .. _., *' I -l 1"1 .. ... ,.,, . .. ,, I

  • i ,I .. \t ~, t I 1 .~ 1 I ., .... ,
  • I I' I * .. . . 1111 *T* t * .. :> \ . I '*' .:

....,.......,..,.....,....--

.... ----*;.**

1926.fflt J;HERGY COMMISSION

' -itlli?i10N ,o n>>.'OAAI> ,OAu ee

  • WASHINCtON, o.c. 20545 I '* F'ORM ).ppnove:o
r~~:r~*M:?,.,.,, PERsoNHE1:.

sEcuR1rv*

ouEs110Ni

    • RE , 0*M*0*.!$,R 0**,. ~-NAME (J-111,. f'na,, M14,ii.) _, / .,...,. $0CfA\. Ste. NO, ' 11* tlAME OF .AGI: OR FIRM EMPLOnN~ !t~.z/JT,~

?2>&1i1Hf Pc DY/ ; .. "'!i(~) ~6_) _ _ .. . , _ . _ At.£_ e . 1 . _ ,. *

  • 1NSTRUCTIONS,-:.~OMP1.ST£ THIS FORM IN PRIVATE, ALf. SECTIONS MUST BE COMPLETED.

FORJA WILt. NOT Be ACCEPTED*

t/NLESS ~Mfitfi'tEL'f.

'Atll1 i>ROPERf.Y EXECUTED.

T~ oniwet$ or stafc1M11,s on this for,,. ore p1lvilc9cd inlortr.otlor, between ro" cw! the Govcrnmenr, Tf Pe OR PRINT ALL ANSWERS. Write. "'None when cppllco61e, Enter ht lie,..,. J 1 Qfl'/ ot!rJltiol'IOI ln(ormoll,on, which 1110)' liCNe O hor/n9 on Y0!.11 sccu,Ur elecvonc1t, t( more $pOC:C Is teqvJred, c;olfocl.

Otldirlonol sneets ond lt1dlcol1t ffiit I rem l)l,ll))Otrs to wPllc1t th. onswe,s or,ply * ., $A. Iv* Jou Mw, wlt~H'JI th* lo,, 10 v*** lttv* yow~,._, o Me,nl,o, of ony o,t90IH101;0,.

or 9rout ~* t*1101t1 lr-crv,fft9 lvt "' llmlt~d to tll* eo-u,.,,, Po,1y, U.$.A,, wi.1,t., '""t 1h* p*rlff of YOYI' tlltMhrtl.lp ot ouoclotiOII you lc,-.w wos o4vo,otint ftochlftf t!.ot tltt Cov**flm4nt of *"* U11ittd $toru, o, 011y $tot, o, Oft)" "litleol 111'l>olvhl0ft th.roof tltovld'" ovtrtlirowft o, ovtOllfllod iy lor,*, ¥lol*11~*, or Ol'I'/ y11lowful 1111011s?

8. If Y<>w 0111we, to A ** "Y**"* 411 yov, 411rl~ 11'* ,eilff of sue~ m*Mberalll~

or ostodoti~, llovo th sp*cWc f1ue11t to f111th* th* 011111, c-1 uch ~90'tla011011 o0t 9rqvp of p,r10t1* to overtllrow o, ovtllurll th* Govtrftfll*nl of the U\ltod $101 .. or Oft'/ $tot* o, ony oolltlcol 1~<11-.,1,1~

thereof \,y fore*, vl0Te11ct, c,, ynlowful Mt<Hls? 6, If yow 011,w,r ,o Qu.,,rlor,1 4, or $4_. *v* I* "Y**", ,101* ~,low, Ylldet II** No. n, °" '°" o np11rote shnt 10'"0 ouo~t,.,d 10 o"i 1110'!* o port of t1ua I 'lllt*lltMOlr*, *lo* f'IOMU of olt svc\ or110l'l1otl0111 dotu ,of 1111t111N11hlp.

Gin c01111ltto 4ttolh of )IOI/I o~rMtln th***i" 0"' Nk* or,y *rrl011otlo11

)'OU dolt* ,t;oroi11t yOVt"AMfllt~*r*l.li) or oc.tlvitlu, NAMt: ADORE$$ f'ROM TO 8, Hav9 ,-~ ,.,.,, '"" orruttd, cho,oe4. *.,U l>y fe<ltrol, $tot,, o* othtr low ,11,orcn1el'tt oi,rhorltlt11 tor O"Y v:olotlo11 of 11ny fe4t,o1 low, $tott low, ~O!l"Y or m..,nJ~lpol l~w, ro111lotlo11, Of ordh1~u'l Do°' l11d114, on)'thlno tho, ho1per..d l>tfo*, yovi 16tt, blrrMgy. Do o11ot *,11cfyh trorhc violotlorn lo, wMcfi fiM of $30,00 or ftu v,o* *1111pottl, AU o,.,,, d1q,ou r-w,t i, lncl.id.4 ,v,11 lf_th*y wtrt dh1111u,4, * * * , If yw, -.itawer h "Yea", ~-Ofl'IPl~te a.H Mttlu 111 JtM t, b,tow. OFFICE HELO -** ., 9. I.RRE$T$ (COll'lpt,,.

A,e.c. 011,I O ,~ '°'"' co.o. f11cf114*

ol I ,orrutf GM ,, .... otl,tr ffiC'I\ mlrao* trofllc. vlolotlo,n' ,vo if tt., chorg, f wero diu,in-4,)

A, OAU ~. CHARGE c;.

0, ACY&ONYAK[N

/Ye?//£ I* 'y'r' *, . 10, PREVIOUS $E.CURITY"CLEARANCE OR ACCESS AUTHORIZATIONa * * \ *, .,, A, To YOl/t' lr.Mwl*49*

fioY~,YW .v*r ~*~I\ hlYHtl;oted

\y OJ'I)' \uoa'>ch ol rht F*4tto1 Gov'e,-,iltt

-. & \ I"\, ,._,;., ..... , I I, t' ...... ~. " &. To yov,, k110wfe,f~*

"*"* yw ever Ii**" HfvsH cltfl'*~*

or o~J*u ovt*.o,botlon

  • Y ,:rr; t.fo11ch of tht ftlerol Qov*t1111Mnlf If y~r Ol'Jwet ,~ ettJ..., A o,r 8 11 "Y*f", pf*ost f.,nl*h 4troil, In 11,1a U. '*-.. I..::~:*..

.. I

  • I *' CERTIFICATION*,..
  • ... ' ... Ill; I ,1 I f .. NO ~~Cl o**~ .... . I 41. -L Ill I*~* --------------,=.-------

"--*

i I I t I I ;;

II ... ;~ti/~-(/*.

'p~~/2;-~/H

  • ,,;,. , EJ>UCATIQX (Ml ~ow&kmen/4~) " .. -~* ...... *:;:a . J *-.... ~t1r,11 s~'Qc ~Id;, 4".:t'l,,'4/-?;t!-

4-.. .:r. 'f'~d'ec.e"i!'-c

-~~At') * ~:t.!#~t.~~.i:.-

/1/.Y. ~1(/;;;'rhr~

.11~k&$'/fb-~

~.b.)-r)e .. , .. -* . . . *-, .. _ //,}y IF.;),9 ,,1,"'(Y-:.: . /?.J..? ~S/ * /f~J /~f&.7 $/!:Jc APl)RE$ *, I I I I I l I

Retrieved from "https://kanterella.com/w/index.php?title=ML19053A689&oldid=1346295"