Part 25, page 376

Transcript

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Form Approved Budget Bureau No. 22-R248

INSTRUCTIONS: Five (5) copies of accomplished form will be submitted by the Contractor when [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. FORM WILL NOT BE ACCEPTED UNLESS COMPLETELY AND PROPERLY EXECUTED, [illegible] Items which do not apply will be marked "None"

NOTE: A PENALTY FOR MISREPRESENTATION - Title 18 United States Code, 1001 makes it a criminal offense, punishable upon conviction of a fine, imprisonment, $10,000 fine, or both, to make a false statement or representation to any Department or Agency of the United States to any matter within the jurisdiction of any Department or Agency of the United States. This includes any statement knowingly made by employee or employee herein which is found to be incorrect, incomplete or withholding legally important particulars - Title 18 United States Code, 911 states a whoever falsely and willfully represents himself to be a citizen of the United States shall be fined not more than $1,000 or imprisoned not more than three years, or both.

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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

NAME AND ADDRESS OF EMPLOYER (If a subsidiary, include name of parent company) THE BOEING COMPANY AERO - SPACE DIV[ISION] SEATTLE, WASHINGTON 7755 E. MARGINAL [WAY]

JOB TITLE AND DESCRIPTION OF EMPLOYEE'S DUTIES WHICH REQUIRE ACCESS TO CLASSIFIED INFORMATION [redacted - b6/b7C]

CONTRACT NUMBER, WHEN APPLICABLE [redacted - b7C]

SECURITY CLASSIFICATION OF MATERIALS OR INFORMATION EMPLOYEE WILL HAVE ACCESS TO [redacted - b6/b7C]

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.

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TO BE COMPLETE[D]

1. LAST NAME - FIRST NAME - MIDDLE NAME [redacted - b6]

[illegible field - ANY OTHER [illegible] NAME(S)] [redacted - b6/b7C]

2. DATE OF BIRTH 4. PLACE OF BIRTH [redacted] [redacted]

5. SOCIAL SECURITY NO. [redacted - b7C]

[MARITAL STATUS] 7. SEX 8. RACE 9. HEIGHT 10. WEIGHT 11. COLOR [eyes] [hair] [redacted] Male White 6'1 195 Blue Black

EDUCATION (Account for all civilian schools) YEARS (Include month if known) GRADUATE [redacted/partially visible: [guess: some text]]

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NATURALIZED CITIZEN ONLY, COMPLETE 14 THROUGH 21

14. FORMERLY CITIZEN OF WHAT COUNTRY 15. DATE AND PLACE OF ENTRY INTO UNITED STATES [blank] D

16. CITY, COUNTY, AND STATE WHERE NATURALIZED 17. COURT [blank] [blank]

18. DATE 19. CERTIFICATE NUMBER 20. FORMER ALIEN REG. NO. [blank] [blank] [blank]

21. DERIVATIVE CITIZENSHIP A. PARENT'S NAME B. CERTIFICATE NUMBER [illegible/blank]

C. PLACE OF NATURALIZATION d. COURT e. DATE(S) [illegible] [illegible/blank] [illegible]

DD FORM 48 REPLACES EDITION OF 1 MAR 55, WHICH IS OBSOLETE.

MILITARY SERVICE

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DB Cooper-8446