Part 101, page 155

Transcript

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SUPPLEMENTAL INFORMATION SHEET

The following information is necessary to supplement your application. All questions must be answered fully. Write "None" where applicable.

Name: Peterson, Sheridan, Louis LAST FIRST MIDDLE Social Security No. [guess: 565]-30-858[guess: 4]

Place of Birth: Santa Rosa, California CITY STATE OR COUNTRY

Wife's full maiden name or Husband's name: [blank]

Father's full name: Chauncey Weaver Peterson Windsor, Calif deceased BIRTHPLACE PRESENT ADDRESS

Mother's full name including maiden name: Mrs Edith [guess: Koffee] (Peterson) Crane Lincoln, Calif Santa Rosa, Calif BIRTHPLACE PRESENT ADDRESS

List names and addresses of relatives and dependents living outside the United States or its Possessions: none

List all organizations, other than labor unions, to which you have ever belonged. (PAST AND PRESENT): Washington Education Association, National Education Association, Montana Education Association, VF[guess: W] [illegible]

Have you ever changed your name or gone by any other name? Yes ___ No X

NOTE: Females must answer "Yes" if married, and list all married names ever used.

If "Yes" indicate names used and dates of changes: [blank]

Authority for the change: [blank]

Date: 4/27/62 Signature: [handwritten signature, partially legible]

DB COOPER 45617