Part 101, page 146

Transcript

The scan is the source; the transcript is machine-generated from it.

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]