Part 101, page 149

Transcript

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

[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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