Part 25, page 385
Document date 27 April 1962
FBI 164-81, Vault Part 25 p. 385 (DB Cooper-8455), Form, dated 27 Apr 1962 — cooper.theunsolved.net/parts/Cooper-Part-25/pages/385
Transcript
The scan is the source; the transcript is machine-generated from it.
SUPPLEMENTAL INFORMATION SHEET
The following information is necessary to supplement your application. All questions must be answered fully. Write "None" where applicable.
Name [REDACTED b6/b7C] ____DDLE____ Social Security No. [REDACTED b6/b7C]
Place of Birth [REDACTED b6/b7C] ____NTRY____
Wife's full maiden name or Husband's name [REDACTED b6/b7C]
Father's full name [REDACTED b6/b7C] BIRTHPLACE: Windsor, Calif PRESENT ADDRESS: deceased
Mother's full name including maiden name [REDACTED b6/b7C] PRESENT ADDRESS: Calif, Santa Rosa, Calif
74. List names and addresses of relatives none and dependents living outside the ____ United States or its Possessions ____
75. List all organizations, other than labor unions, to which you have ever belonged. (PAST AND PRESENT) [REDACTED b6/b7C]
76. Have you ever changed your name Yes ____ or gone by any other name? 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 ____
Authority for the change ____
Date 4/27/62 Signature [REDACTED b6/b7C]
U3 4138 7000 REV. 3/61 DB Cooper-8455