Part 81, page 32
Document date 9 December 1971
FBI 164-81, Vault Part 81 p. 32 (DB Cooper-35375), Form, dated 9 Dec 1971 — cooper.theunsolved.net/parts/Cooper-Part-81/pages/32
Transcript
The scan is the source; the transcript is machine-generated from it.
ANSWER ALL QUESTIONS
PERSONS GIVING FALSE INFORMATION OR FIC- TITIOUS NAMES WILL BE PUNISHED UNDER THE LAW A.R.S. 28-472.
HAS YOUR LICENSE EVER BEEN REFUSED, SUSPENDED, OR REVOKED? YES ☐ NO ☒
HAVE YOU EVER BEEN ADDICTED TO DRUGS? YES ☐ NO ☒
HAVE YOU EVER BEEN COMMITTED TO A MENTAL INSTITUTION BY A COURT? YES ☐ NO ☒
HAVE YOU EVER BEEN SUBJECT TO EPILEPSY, FAINTING SPELLS OR SEIZURES RESULTING IN UNCONSCIOUSNESS? YES ☐ NO ☒
GIVE DETAILS ON ANY QUESTION ANSWERED "YES" IN SPACE PROVIDED ON REVERSE SIDE
AS A CONDITION OF BEING LICENSED, I UNDERSTAND AND AGREE THAT FUTURE SUSPENSION OR REVOCATION NOTICES, IF ANY, MAY BE MAILED TO ME AT THE ADDRESS SHOWN HEREON.
ACCEPTANCE OF LIABILITY BY PARENTS OR GUARDIAN OF APPLICANTS UNDER 18 YEARS OF AGE
PURSUANT TO SECTION 28-417A ARIZONA CODE AS AMENDED AND IN ASSUMPTION OF THE LIABILITY THEREIN, THE UNDERSIGNED HEREBY SWEARS THE ANSWERS ARE TRUE AND CORRECT.
FATHER _______________
M. V. D. AGENT - OR - NOTARY PUBLIC SUBSCRIBED AND SWORN TO BEFORE ME ON_______________
MY COMMISSION EXPIRES_______________
MOTHER_______________
M. V. D. AGENT - OR - NOTARY PUBLIC SUBSCRIBED AND SWORN TO BEFORE ME ON_______________
MY COMMISSION EXPIRES_______________
AMD 40-058 R8-70 (400M 8-70)
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W 325
ARIZONA CLASS 2 SEE REVERSE SIDE FOR CORRECTIONS LICENSE NUMBER MR MISS FIRST NAME MIDDLE NAME LAST NAME MRS. EUGENE LEROY WATSON B908[guess: 67]
STREET EXPIRES ADDRESS P.O. BOX 758 - BELL LANE ON YOUR 1972 BIRTHDAY RENEW WITHIN 30 DAYS PRIOR CITY OR POST OFFICE JEROME ARIZ. 86331
SEX WEIGHT EYES HEIGHT HAIR RESTRICTIONS M 190 BLU 6'1" BR
DATE OF BIRTH DATE OF ISSUE DEC 31 27 NOV 27 1970 NOV 27 197[illegible] DATE PAID X Eugene [guess: L.] Watson (SIGNATURE OF APPLICANT) 004969 SUPERINTENDENT RECEIPT NUMBER MOTOR VEHICLES
OCCUPATION: PRESIDENT - CRYSTAL PHYSICS
HOW LONG HAVE YOU OPERATED A MOTOR VEHICLE? 27 YEARS
LAST NAME
I HEREBY CERTIFY THAT ALL STATEMENTS ON THIS APPLICATION ARE TRUE
[SUBSCRIBED AND SWORN] TO [BEFORE ME] THIS 5 DAY OF _____ 19[illegible] X Eugene L. Watson SIGNATURE OF APPLICANT
ARIZONA HIGHWAY DEPARTMENT MOTOR VEHICLE DIVISION DAVID H. CAMPBELL, SUPERINTENDENT
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SE-164-81-1A
DB Cooper-35375
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[guess: R] 10/6/[illegible]
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b6 b7C