Part 26, page 26
Document date 17 December 1970
FBI 164-81, Vault Part 26 p. 26 (DB Cooper-6647), Form, dated 17 Dec 1970 — cooper.theunsolved.net/parts/Cooper-Part-26/pages/26
Transcript
The scan is the source; the transcript is machine-generated from it.
[illegible partial text at top edge] for [illegible] items. Indicate item number and each [illegible] cycle No. ___ Description of work cont.
[Empty lined rows for continuation of work description]
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[If space is required, use full sheets of paper approximately the same size as this page. Write on EACH sheet your name, both date, and examination number/s title. Attach all sheets to this Statement at the top of Page 1]
ATTENTION: READ THE FOLLOWING PARAGRAPH CAREFULLY BEFORE SIGNING THIS STATEMENT
A false answer to any question in this Statement may be grounds for not employing you, or for dismissing you after you begin work, and may be punishable by fine or imprisonment (U.S. Code, Title 18, Sec. 1001). All statements are subject to investigation, including a check of your fingerprints, police records, and former employers. All the information you give will be considered in reviewing your Statement and is subject to investigation. A false answer to Items 23 A or B could deprive you of your right to an annuity when you reach retirement age in addition to the penalties described above.
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CERTIFICATION I CERTIFY that all of the statements made in this Statement true, complete, and correct to the best of my knowledge belief, and are made in good faith
SIGN: [redacted] DATE: Dec. 17, 1970
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DO NOT WRITE IN THIS BLOCK—FOR USE OF EXAMINING OFFICE ONLY
Refer for medical action [ ] Medical action Approved by [ ] Disapproved (reason)
— DB Cooper-6647
[Grid with column headers, partially legible:] Senior [ ] Approv. [ ] Disapprov. Form Reviewed / Item Approved / Option [ ] Referred [ ] Advanced [illegible columns] Initials / [illegible] / 5 Years (Yes) / 10 Points / Comp. Dis / Old / 10 Points / Dual / [illegible] / Drug / [illegible]
THIS SPACE FOR USE OF APPOINTING OFFICER ONLY [ ] 3 Pt. [ ] 10 Pt. Comp. Disab. [ ] 10 Pt. Other Preference has been verified through proof that the separation was under honorable conditions, and other proof as required.
Signature and Title Agency
499 416-60943 1 1960 204-470
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b6 Per BOC b7C Per BOC