Part 41, page 73

Transcript

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

STATEMENT OF PERSONAL HISTORY

INSTRUCTIONS: Read the certification at the end of this questionnaire before entering the required data. Print or type all answers. All [illegible] ...

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15. LIST ALL RESIDENCES FROM 1 JANUARY 1937

MONTH AND YEAR STREET AND NUMBER CITY STATE OR COUNTRY FROM - TO Jun 37 Nov 40 Unknown Selah Washington Nov 40 Jul 46 1116 Jefferson Yakima Washington Jul 46 Jun 52 Box 70 Skykomish Washington Jun 52 Sep 52 1314 Minor Seattle Washington Sep 52 Mar 53 4761 - 21st NE Seattle Washington Mar 53 Mar 56 U. S. Army Mar 56 Feb 57 4403 - 24th West Seattle? Washington Feb 57 Apr 58 13000 Aurora Seattle Washington Apr 58 May 58 1503 - 18th Avenue #104 Seattle Washington May 58 Apr 61 9215 - 12th NE Seattle Washington Apr 61 Present 6814 - 30th NE Seattle Washington

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16. PAST AND/OR PRESENT MEMBERSHIP IN ORGANIZATIONS

NAME AND ADDRESS TYPE (Social, fraternal, professional, etc.) OFFICE HELD MEMBERSHIP FROM - TO YMCA Yakima, Wash. Yakima Boys Club - Mar 45 Mar 46 Boys Scout of America Boys Club - Mar 45 Mar 46 Pershing Rifles-Univ of Washington Drill Team - Oct 52 Mar 53 BPOE Elk #92 Seattle Fraternal None Apr 58 - Footprinters Intl Fraternal None Nov 62 Present

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17. YES NO X ARE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF THE COMMUNIST PARTY U. S. A., OR ANY COMMUNIST ORGANIZATIONS ANYWHERE? X ARE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF A FASCIST ORGANIZATION?

ARE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF ANY ORGANIZATION, ASSOCIATION, MOVEMENT, GROUP OR COMBINATION OF PERSONS WHICH ADVOCATES THE OVERTHROW OF OUR CONSTITUTIONAL FORM OF GOVERNMENT, OR WHICH HAS ADOPTED THE POLICY OF ADVOCATING OR APPROVING THE COMMISSION OF ACTS OF FORCE OR VIOLENCE TO DENY OTHER PERSONS THEIR RIGHTS UNDER THE CONSTITUTION OF THE UNITED STATES, OR WHICH SEEKS TO ALTER THE FORM OF GOVERNMENT OF THE UNITED STATES BY UNCONSTITUTIONAL MEANS? X ARE YOU NOW OR HAVE YOU EVER BEEN AFFILIATED OR ASSOCIATED WITH ANY ORGANIZATION OF THE TYPE DESCRIBED ABOVE AS AN AGENT, OFFICIAL, OR EMPLOYEE? X ARE YOU NOW ASSOCIATING WITH, OR HAVE YOU ASSOCIATED WITH ANY INDIVIDUALS, INCLUDING RELATIVES, WHO YOU KNOW OR HAVE REASON TO BELIEVE, ARE OR HAVE BEEN MEMBERS OF ANY OF THE ORGANIZATIONS IDENTIFIED ABOVE? X HAVE YOU EVER ENGAGED IN ANY OF THE FOLLOWING ACTIVITIES OF ANY ORGANIZATION OF THE TYPE DESCRIBED ABOVE: CONTRIBUTION(S) TO, ATTENDANCE AT OR PARTICIPATION IN ANY ORGANIZATIONAL, SOCIAL, OR OTHER ACTIVITIES OF SAID ORGANIZATIONS OR OF ANY PROJECTS SPONSORED BY THEM; THE SALE, GIFT, OR DISTRIBUTION OF ANY WRITTEN, PRINTED, OR OTHER MATTER, PREPARED, REPRODUCED, OR PUBLISHED, BY THEM OR ANY OF THEIR AGENTS OR INSTRUMENTALITIES? X

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IF "YES," DESCRIBE THE CIRCUMSTANCES. ATTACH ADDITIONAL SHEETS FOR A FULL DE[illegible]MENT. [illegible] ORGANIZATIONS, SPECIFY NATURE AND EXTENT OF ASSOCIATION WITH EACH, INCLUDING OFFICE OR POSITION HELD, ALSO INCLUDE DATES, PLACES, AND CREDENTIALS NOW OR FORMERLY HELD. IF ASSOCIATIONS HAVE BEEN WITH INDIVIDUALS WHO ARE MEMBERS OF THE ABOVE ORGANIZATIONS, THEN LIST THE INDIVIDUALS AND THE ORGANIZATIONS WITH WHICH THEY WERE OR ARE AFFILIATED.

N/A

This material copied from records of National Personnel Records Center, St. Louis, Missouri, to be used for reference only. Do not recopy or disseminate in its original form outside the Bureau.

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18. HAVE YOU EVER BEEN DETAINED, HELD, ARRESTED, INDICTED OR SUMMONED INTO COURT AS A DEFENDANT IN A CRIMINAL PROCEEDING, OR CONVICTED, FINED, OR IMPRISONED OR PLACED ON PROBATION; OR HAVE YOU EVER BEEN ORDERED TO DEPOSIT BAIL OR COLLATERAL FOR THE VIOLATION OF ANY LAW, POLICE REGULATION OR ORDINANCE (excluding minor traffic violations for which a fine or forfeiture of $25, or less was imposed)? INCLUDE ALL COURT MARTIALS WHILE IN MILITARY SERVICE. [] YES [X] NO IF "YES," LIST THE DATE, THE NATURE OF THE OFFENSE OR VIOLATION, THE NAME AND LOCATION OF THE COURT OR PLACE OF HEARING, AND THE PENALTY IMPOSED OR OTHER DISPOSITION OF EACH CASE.

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DB-Cooper-12003