Department of Defense Personnel Security Questionnaire for Sheridan Louis Peterson with Boeing attachment sheet
Document date 10 September 1962
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Id: Cooper-Part-101:146-150
Subject: Cooper Files: Cooper-Part-101:146-150 Document: Department of Defense Personnel Security Questionnaire for Sheridan Louis Peterson with Boeing attachment sheet Id: Cooper-Part-101:146-150 Page: https://cooper.theunsolved.net/documents/Cooper-Part-101%3A146-150 What is wrong (title, date, type, which pages belong together, copies)? What does the scan show?
A person reads every report. Corrections are made by hand, to the data — titles, dates, names, which pages belong together — never to the scans, and they can take a while to appear.
FBI 164-81, Vault Part 101 pp. 146–150 (DB Cooper-45608–45612), Form, dated 10 Sep 1962, serial 565-30-8586 (as read from the transcript) — cooper.theunsolved.net/documents/Cooper-Part-101%3A146-150
DEPARTMENT OF DEFENSE PERSONNEL SECURITY QUESTIONNAIRE DATE: SEP 10 1962
INSTRUCTIONS: Five (5) copies of accomplished form will be submitted by the Contractor [illegible] [illegible] investigation for clearance by a military department is required. TYPE OR PRINT ALL ANSWERS. If more space is required, attach additional sheets, identifying by corresponding block number. [illegible] FORM WILL NOT BE ACCEPTED UNLESS COMPLETELY AND PROPERLY EXECUTED, [illegible] [illegible] items which do not apply will be marked "None"
NOTE: PENALTY FOR MISREPRESENTATION - Title 18 United States Code, [section details regarding false statements, $10,000 fine, or both, to make a false statement or representation to any Department or Agency of the United States...]
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TO BE COMPLETED BY EMPLOYER
TO: (Cognizant Security Office) AIR FORCE PLANT REPRESENTATIVE THE BOEING COMPANY 7755 E. MARGINAL WAY SEATTLE, WASHINGTON ATTN:
NAME AND ADDRESS OF EMPLOYER (if a subsidiary, include name of parent company) THE BOEING COMPANY AERO-SPACE DIVISION SEATTLE, WASHINGTON 7755 E. MARGINAL WAY
JOB TITLE AND DESCRIPTION OF EMPLOYEE'S DUTIES WHICH REQUIRE ACCESS TO CLASSIFIED INFORMATION:
Editor 2-5812-00
CONTRACT NUMBER, WHEN APPLICABLE: [illegible] SECURITY CLASSIFICATION OF MATERIALS OR INFORMATION EMPLOYEE WILL HAVE ACCESS TO: [illegible]
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I CERTIFY THAT THE ENTRIES MADE BY ME ABOVE ARE TRUE, COMPLETE, AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF AND ARE MADE IN GOOD FAITH.
TO BE COMPLETE 1. LAST NAME - FIRST NAME - MIDDLE NAME [guess: PETERSON] Sheridan Louis
3. DATE OF BIRTH 4. PLACE OF BIRTH May 2, 1926 Santa Rosa, California
5. SOCIAL SECURITY NO. [redacted - b6/b7C]
6. MARITAL STATUS 7. SEX 8. RACE 9. HEIGHT 10. WEIGHT 11. COLOR EYES 12. COLOR HAIR Separated Male White 6'1 195 Blue Black
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13. EDUCATION (Account for all civilian schools)
YEARS (Include month if known) NAME AND LOCATION OF SCHOOL GRADUATE DEGREE FROM TO YES NO 9-1934 6-1936 Hill School - Sonoma Co., California x 9-1936 6-1939 Windsor - Windsor, California x 9-1939 2-1942 St. Vincent's - San Rafael, California x 2-1942 6-1944 Healdsburg High School, California x 10-1946 2-1947 Healdsburg High School, California 2-1947 6-1949 Santa Rosa Jr. College, California x A.A. 9-1949 6-1952 University of Missouri - Columbia, Missouri x [guess: B.J.] 9-1953 2-1954 University of Missouri - Columbia, Missouri x 9-1954 3-1955 Montana State University - Missoula, Montana Summers of 1956 & 1957 Montana State University - Missoula, Montana x
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14. FORMERLY CITIZEN OF WHAT COUNTRY
15. DATE AND PLACE OF ENTRY INTO UNITED STATES D 16. CITY, COUNTY, AND STATE WHERE NATURALIZED
17. COURT
18. DATE 19. CERTIFICATE NUMBER 20. FORMER ALIEN REG. NO.
21. DERIVATIVE CITIZENSHIP A. PARENT'S NAME [illegible]
A. CERTIFICATE NUMBER
DB COOPER-45608
A. PLACE OF NATURALIZATION A. COURT [illegible] A. DATE [illegible]
MILITARY SERVICE COUNTRY: U.S.A. BRANCH OF SERVICE: Marine Corps SERVICE NUMBER: 557214 OM (Date): 4-25-44 TO (Date): 12-16-4[4]
TYPE OF DISCHARGE: Honorable 234. LOCAL DRAFT BOARD (United States) AND ADDRESS: DNA A. ORDER NO.: DNA C. CLASSIFICATION: DNA
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RESIDENCE (List all places of residence from 1 Jan 1957, starting with present) STREET, CITY, STATE, OR OTHER POLITICAL SUBDIVISION AND COUNTRY | FROM (Date) | TO (Date) [1] 30th Ave. South, Seattle 44, Washington | 5-62 | PRESENT [8] Abert Street, Richland, Washington | 8-61 | 5-62 [5] South Bowdish, Spokane 63, Washington | 6-60 | 8-61 [R]. Ronald Pinkham Place - Lopez Island, Washington | 9-58 | 6-60 [5]6 Division Street, Moses Lake, Washington | 9-57 | 9-58 Ravalli Street, Missoula, Montana | 6-57 | 9-57 x 721 - Noxon, Montana | 9-55 | 6-57 [7][?]South Third Street, West, Missoula, Montana | [5]-55 | 9-55 [3] South First, West, Missoula, Montana | 1-55 | 5-55 [1]0 [Fine] Street, Missoula, Montana | 9-54 | 1-55 [Sm]okejumper Headquarters - Parachute Loft; Missoula, Montana | 6-54 | 9-54 [1]15 Paquin, Columbia, Missouri | 3-54 | 6-54 South 5th, Columbia, Missouri | 10-53 | 3-54 [Sm]okejumper Headquarters - Parachute Loft; Missoula, Montana | 6-53 | 10-53 [1]0 College Ave., Columbia, Missouri | 2-53 | 6-53 [1]05 Paris Road, Columbia, Missouri | 9-52 | 2-53 [L]tcher Logging Camp - Annapolis, California | 6-52 | 9-52 [1]0 Gentry Place, Columbia, Missouri | [illegible] | 6-[52] (see attachment sheet)
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ORGANIZATIONAL MEMBERSHIP [Lis]T ALL ORGANIZATIONS EXCEPT LABOR UNIONS AND EXCEPT ORGANIZATIONS LISTED ON DO FORM 484 IN WHICH YOU HOLD OR [HA]VE HELD MEMBERSHIP
NAME AND ADDRESS | TYPE | OFFICE HELD | FROM (Date) | TO (Date)
Moses Lake, Washington: National Assoc. for the Advancement of Colored People | Humanistic | Publicity D[i]r[ec]tr. | 6-58 | 6-59
Wash. Education Assoc. [Se]attle, Washington: | Professional | None | 9-57 | 6-58
Boeing Skydiving Club [N]oxon, Montana: | Athletic | Vice President | 6-62 | PRESENT
Montana Education Assoc. | Professional | None | 9-55 | 6-56
Parent-Teachers Assoc. | Social | None | 9-55 | 6-60
[Lo]pez and Medical Lake, Wn: Parent-Teachers Assoc. | Social | None | 9-55 | 6-60
Columbia, Missouri: Veterans [of] Foreign Wars (Post 280) | Social | None | 2-50[?] | 2-52
[Sa]n Francisco, California: Marine [guess: Memorial] Assoc. | [guess: Social] | [illegible] | 6-[4]8 | [illegible]
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DB COOPER-45609
FOREIGN COUNTRIES VISITED OR RESIDED IN
[illegible form number/header] | DATE LEFT U.S. | DATE RETURNED U.S. | PURPOSE
(S[illegible]) Guaymas, Mexico 6-52 6-52 Tourist [several additional entries below, largely illegible due to scan quality] [illegible entries with partial dates and locations visible]
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27. RELATIVES a. LIST PARENTS, SPOUSE, (including maiden name) CHILDREN, BROTHERS, AND SISTERS (16 years and older). LIST EVEN THOUGH DECEASED
RELATION | NAME | ADDRESS (Enter "deceased" if no longer living) | PLACE & DATE OF BIRTH | PRESENT CITIZENSHIP
Mother Edith (EMM) Crane 1542 Bookside Drive, Lincoln, Calif. U.S.A. Santa Rosa, California 6-yr. unknown
Step- Fredrick L. Crane Same as above Unknown U.S.A. father
Father Chauncey W. Peterson Deceased Windsor, Calif. Date unknown
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a. LIST OTHER LIVING RELATIVES AND RELATIVES OF SPOUSE KNOWN TO BE RESIDING OUTSIDE THE UNITED STATES
NONE
[mostly blank area with some illegible markings]
DB COOPER-45610
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28. EMPLOYMENT (Show every employment you have had since 1 Jan 1937 and account for all periods of unemployment)
POSITION HELD | EMPLOYER AND IMMEDIATE SUPERVISOR | ADDRESS | FROM (Date) | TO (Date)
Audio-Visual Boeing Airplane Company Seattle, Wash. 5-62 PRESENT Editor SUPERVISOR Unemployed 2-62 5-62
Reporter & Columbia Basin News Pasco, Washington 8-61 2-62 Feature Writer Unemployed 6-61 8-61
Teacher Medical Lake High School Medical Lake, Washington 9-60 6-61
Reporter & The Spokesman-Review Spokane, Washington 6-60 9-60 Copy Desk Man
Teacher Lopez High School Lopez, Washington 9-58 6-60 Unemployed 6-58 9-58
Teacher Moses Lake High School Moses Lake, Washington 9-57 6-58
Timber Region I - U.S. Forest Serv. Missoula, Montana 8-57 9-57 Cruiser
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b6 b7C
[illegible header/form number]
AVE YOU EVER BEEN ARRESTED, CHARGED, [illegible] HELD BY FEDERAL, STATE, OR OTHER LAW E[NFORCEMENT] AUTHORITIES, FOR ANY VIOLATION OF ANY FEDERAL LAW, STATE LAW, COUNTY OR MUNICIPAL LAW, REGULATION OR ORDINANCE? INCLUDE ALL COURT MARTIALS, WHILE IN MILITARY SERVICE. DO NOT INCLUDE ANYTHING THAT HAPPENED BEFORE YOUR,16TH BIRTHDAY. DO NOT INCLUDE TRAFFIC VIOLATIONS FOR WHICH THE ONLY PENALTY IMPOSED WAS A FINE OF $25.00 OR LESS. ALL OTHER CHARGES MUST BE INCLUDED EVEN IF THEY WERE DISMISSED. ]YES [X]NO IF "YES", GIVE DATE AND PLACE, CHARGE, AND DISPOSITION:
[multiple lines of illegible handwritten or typed entries]
* [illegible] * [guess: SEATTLE] [illegible] [illegible entries continue]
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HAVE YOU EVER BEEN PREVIOUSLY GRANTED OR DENIED A SECURITY CLEARANCE BY THE DEPARTMENT OF THE ARMY, NAVY, OR AIR FORCE, BY ATOMIC ENERGY COMMISSION OR OTHER GOVERNMENT AGENCY? IF "YES", INDICATE WHEN GRANTED, WHERE, AND BY WHOM; IF DENIED, WHEN AND BY WHOM
A. GRANTED A. DENIED ]YES [X]NO ]YES [X]NO
32. WHAT WAS THE LEVEL OF THE CLEARANCE?
N/A N/A
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REFERENCES (Give five personal references, stating business address of all references, if known. Do not include relatives, former employers, or persons living outside the United States.)
[illegible] | YEARS | [illegible] | CITY | [illegible] | STATE | [entries present but largely illegible due to scan quality] [illegible rows of reference information]
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[illegible certification/legal text]
[several illegible lines]
LIST ALL FOREIGN OWNED CORPORATIONS OR OTHER [illegible] OWNER, OR ACT IN A REPRESENTATIVE CAPACITY. (If none, so indicate).
NONE
[illegible entries]
DB COOPER-45611
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CERTIFICATION
WARNING: Read every [guess: instance] of Certification before signing.
I certify that the entries made by me above are true, complete, correct to the best of my knowledge and belief, and are [made] in good faith. [illegible] [I] certify that I am a citizen of the United States.
I certify that I know that any misrepresentation or false state- ment made by me herein may subject me to prosecution under Section 1001 of the United States Criminal Code, with penalties up to five (5) years imprisonment and $10,000 fine.
I certify that I have read and understood each sentence of this Certification.
SIGNATURE OR MARK OF EMPLOYEE | DATE OF SIGNATURE [illegible signature] [guess: 12/86] [guess: 10/1983] [illegible]
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b6 b7C
BOEING
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ATTACHMENT SHEET FOR PERSONNEL SECURITY QUESTIONNAIRES OF: SHERIDAN LOUIS PETERSON SS: 565-30-8586 DOB: May 2, 1926
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24. continued Witcher Logging Camp - Annapolis, California 6-51 9-51 Number unknown on South Ave., Columbia, Missouri 9-50 6-51 Number unknown on Harrisburg Ave., Houston, Texas 6-50 9-50 818 Fay Street, Columbia, Missouri 9-49 6-50 Utah Construction Camp - Ukiah, California 6-49 9-49 Number unknown on Sonoma Highway - Santa Rosa, California 9-48 6-49 Crawford Lumber Camp - Longvale, California 6-48 9-48 Santa Rosa Jr. College Dorm., Santa Rosa, California 9-47 6-48 Union Lumber Company Camp, Fort Bragg, California 6-47 9-47 1543 Slater Street, Santa Rosa, California 11-46 6-47 U.S. Marine Corps, Pac. theater of operations 5-44 11-46 Number unknown - Healdsburg, California 7-43 5-44 6158 Faught Rd., Windsor, California 1-37 6-43
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28. continued Green Bonner Lumber Mill Bonner, Montana 6-57 8-57 Chain Worker Teacher Noxon High School Noxon, Montana 10-55 6-57 Reporter The Missoulian Missoula, Montana 6-56 8-56 Choker The Thomas Logging Co. Holland Lake, Montana 8-55 10-55 Setter Choker Harper's Logging Co. Missoula, Montana 6-55 8-55 Setter Timber Region 1 - U.S. Forest Missoula, Montana 3-55 6-55 Cruiser Service Student 9-54 3-55 Smokejumper U.S. Forest Service Missoula, Montana 6-54 9-54 Night Columbia Municipal Lib. Columbia, Missouri 9-53 6-54 Librarian Smokejumper Region 1 - U.S. Missoula, Montana 6-53 9-53 Forest Service Life Guard Hulen Lake Columbia, Missouri 4-53 6-53 Logger Witcher Logging Camp Annapolis, Calif. 6-52 9-52 6-51 9-51 Laborer Utah Construction Co. Ukiah, California 6-49 9-49[guess: 6] Sandblaster Todd Shipyards Corp. Houston, Texas 7-50 9-50 Cub Reporter Santa Rosa Press - Santa Rosa, California 12-48 6-49 Democrat Mill-hand Crawford Lumber Co. Longvale, California 6-48 9-48 Mill-hand Union Lumber Co. Fort Bragg, California 6-47 9-47 Student 12-46 6-52 U.S. Marine Corps 4-44 [guess: 12-46] Laborer Miller's Dehydrating Plant. Healdsburg, California [illegible] [illegible] Laborer Basalt Rock and Gravel Co. Healdsburg, California 10-43 [illegible] Lumber- Barrett Lumberyard Healdsburg, California 9-42 6-43 Jack Student
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DB COOPER-45612 1-37
Serials: 565-30-8586