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— , • RADIO FREE EUROPE .• .t )PERSONAL HISTÓ.I.: ‘outsflONNAIRE FOR ' NON-U.S.tITIZENS

Personal Fraeebbgen Illr Personen, die nicht Staalsbnreer der U. S.A. Old

DATE OP APPLICATIONDatum der lloworbtin g

g . 1:( • C,j

TI!!! PURPOSE OP THIS QUESTIONNAIRE IS TO SECURE TIM NECESSARY INFORMATION ON TIMBASIS OP \MCI! THE EMPLOYMENT SUITABILITY OF Tile APPLICANT CAN 1111 DETERMINED.

. CAUTION • READ TIM ENTIRE QUESTIONNAIRE CAREFULLY BEFORE YOU START TO PILL OUT. TIM ENULISII LANGUAGE WILL PREVAIL IFDIS/7REPANCIES" EXIST RETWEEN IT AND TIM GERMAN TRANSLATION. ANSWERS MUST 1111 TYPEWRITTEN OR PRINTED CLEARLY IN BLOCKLETTERS. EVERY 011ESTION MliST 11E ANSWERED PRECISELY AND CONSCIENTIOUSLY, AND NO SPACE IS TO OU LEFT PLANK. IP A QUESTIONIS TO RE ANSWERED HY EITHER VES OR 'N0', INDICATE 'YES' OR • NO' IN Tilli APPROPRIATE SPACE. IS NIB QUESTION IS INAPPLICABLE.SO INDIcATB fl y SOME APPROPRIATE WORD OR PI/RASE SUCII AS 'NONE' OR NOT APPLICABLE'. ADD SUPPLEMENTARY sHEEFS IPTHERE IS NOT ENDUCII SPACE IN TIIE QUESTIONNAIRE. OMISSIO \ S, FALSE, MISLEADING, OR INCOMPLETE STATEMENTS WILL DISQUALIFYAPPLICANTS FROM, OR RENDER VOID TIIC TERMS OP IIIS OR IIF.It EMPLOYMENI.

Dieser Fragehmien botwerkt die lierbeitilialfung don mlurdeilldren Unterl.nen, Dui Grunt! /leant die Eigrome des WO Bev/ethers ineweiberint cnisdilo•dP it worden kann.WARNUNG: Lescn Sin den gosomlen Freer/bonen torgiiillig dutch, bovor So nit dem Ausidlien beginnen. Frills sidi Untrucchledlichkelten swIsdten doorenrdisrhen Original and der deutsthen Ubersctrung ergeben coition, 1st die / • ticilisibn Ff414(.1 mnflgebend. Die Beantwortung hat In Sehreibmeschlnen.oder in douilitber Modmdtrill to crIttigcn. Dcantworten Sint J•110 Frage gen e u turd gewissentinit und loosen Sin Mina Spoil° tenousgekillt. 1st eine Pripioroil .je • oder ,ncirr nu beantwortcn, verrnerken Sin .In • oder .neht • In der entsprethenden Stella. 1st din Freon 0berNoript nidit stureilend, soglee Siu es roil einem gceignoten Wert odor einem Ausilrird, on, 2. D. •1.109 . 4tier •nitht zutrollend' Holten Sin tr.' ■nsuncisLICtie, nit, 1,111 Indein Fragcbogen omit!ousieldtand Phi: vorge•chen 151. Weglastruppm, lakilte, lueltibrendo oder unvoll.standigo Angnb, bowIrken din Ausschito0ungdes Mort Bewerbers inewerborin) odor din Aulimbung seines fibres! Ansteliongsvemages.

•,, j, NAME IN FULL °list:Incliner

1.14L-ArAtoBen . & I

Napo

#ER-§_eIR name)

........

2, IDENTIJY CAR IL TYPE and NUMEER.liqu04Ausw•Isporgore, Art Binl , .txg 43129' .Wei/mei/4fMST) MIDDLE' (Zwelie, Vol/tame)

3. (4 ) NAME AT BIRTH, IF DIFFERENT FROM ADOVEeburtsnae, lulls abweIthend von dem obleenG m

trire: 6) /3 Ez Ac-lb) HAVE YOU EVER BEEN

Helen Sio jonalo Irgendweld/eIn1

. (c) IP 'YES', GIVE Name,I Polls Wu/)iend, geben

KNOWN BY ANY OTHER NAMES NO fig YES 0ander,in) Nninen ottlUhrt7 Main in

TIME, PLACE AND CIRCUMSTANCES, UNDER ITEM 41Sin Nemen, Zell, Orl und n•bero Umst/indo unter Snail° 41 en.

4. POSITION FOR WIIICII YOU ARE UNDER CONSIDERATION Paten SIo die Mr Sin In Piano kommendo Stellung on

( 10 (OFFICE DIVISION,. R.F.

DRANCH, SES,TION,

e_ .Octlildtkoit

4re64 E/v

ETC.) Dlenststello, H•uptabtellung, Ableilung, Rectal, etc.s—

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f sficw v/c/- c (a) EXACT 1Thit OF POSITION Conan° Berelthoung der Stellung .

P4e4e-TER 61f.4 ,(4.Aeie-,e4R-1(44/, ,(b) LOCATIOV

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Geben Sle eln• kUTIO liesclualbung Ihrer Dlenstobllegenhetonlin Fella IMor Anstellung I

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7. ( 111 DATE BIRTH

2 — cP—Geburlsdsturn 1 (bI PLACE OF BIRTH Geburtroll

1 -13 /::: 14e411E4(1171.4VIK,k . II. COLOR OF EYES Augenterb• I . COLOR OF HAIR Halal

I ARAzi_ni ez, ER te

II. SEX Gesd‘ledit I B. HEIGHT G4034,

o 13. COMPLEXION Haut/alba

77;10. WEIGHT Gowldt1,

7-2II. DESCRIBE ANY SP I. OR OUTSTANDING CHARACTER! TIC 'S CTIDEPITIFYING MARKSBesondero odor auffillige Merkmalo

P /./Iff"'

IS. PREVIOUS' ADDRESSCS DUPING l'AST 20 YEARS Farber* Ansshrilten der letoten 20 Jable

DATES Oaten . STREET CITYSUM. Stadl

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1.0. LIST EACH COUNTRY OF WHICH . 9" ) HAVE NEN A CITIZEN, GIVING DATES AND MAN/ .0 'OP ACQUISITION OF EACH CITIZENSHIPPahren Ste Jodon Stoat (Land) en, di.. a Sieetsbarderschaft Rio bole:len odor hokum, unto? A i a des Zoltpunktos und dor UrnsUlndo la Worn

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17. (a) PULL NAME OP HUSBAND / WIPE (II wile, maiden name) .Voller Nemo des Ehegatton oiler Guinn (Madchonnernel

e € OrLf U 4.11 /Ai, P A.' Al A /1/ /11

(b) OATS OP BIRTH Goburtsdolurn_____

1.3 - / ii - -19 / 4(c) PLACE OP BIRTH Gebtulsozt

I

/3 t-R Li /V(d) PRESENT ADDRESS Gegenwaitigo Anschritt vrA ...I'D (o) PRESENT OCCUPATION GegenwOrlIgo Desdalftlguno

Hzi /v C 41 4- /v - 23 -.6CCTtII 49 7ilEI- R4R-4/4a.tAr , ..../(I) PRESENT NAT •NALITY Cogent...Ertl StaalsegoohOtigknIt I (g) NATIONALITY AT BIRTH SMelsanuoh0119 alt our Zolt dor Goburt

. I /•••*:74e si dbl.. 1... a '

to. CHILDREN KinderNAME Memo DATE OP BIRTH Goburtsdaturn PRESENT ADDRESS GegenwIrtloo AnschrItt OCCUPATION DeschaltIguog

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194 (a) FATHER'S NAME llama do Vella ".... 1lb) D‘ OF BIS.T12,cuptsdst3/ I (c) PLA P

vo#4-Artv-A-..1 . ... _DIRTIIiiiptsktiv I fret

_ . / . zur Zeit do: Goblin..

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. id) IFESENT ADDRESS

ifitiV4..._Gegenwirtige, Archsiit r",,( , 0 1 (et NATIONALITY AT MUTH SteatsangeharIgko

I Y., _._ '-' C'I (01 FEES NT OCCUPATICITI GegeowdrlIge

/ N/ 7.41.Z4E, t27-e• (Ikall_..2,1Z4TIFttealw.irtlgefeSZ.atzangebdrIgkeit

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204 (a) MOTHER'S NAME Name der Mutter I (0)

&. //4'44)NO -034.04 NAVDATE OP BIRTH Geburtsdatum I lc) PLACE OF BIRTH Geburtsort

Ze-r---fcP.4?fr_VI-A-ze- ,. i, 1 (o) NATIONALITY AT BIRTH Stmttsanoil(rIgkolt our Zoit uer Gaboni ' A7-oe 7Jrii4-A-1 (9)

PRESENT OCCUPATION Gegenwirtlge EtoschOltigunr.

fd PRESENT ADDRESS GegenwErtlge AnschrlIt

, r /1(I) PRESENT NATIONALITY Gogenwartigo u drIgkell

-21. RELATIVES Illrothers, Sisters and In•Laws, wherever located)

. EamilienangebSrige (Eauler, Schwestem, Schwleoerellern, Sthwtegersöhno arid . tdcbter. Sdwigor and SdtwagerInnee, wo sle sich auch aulhalten)

. NAME Name RELATIONSHIPVii wandtsdallso rad

NATIONALITYStaatsangehOrIgkeit ADDRESS Ansdulit OCCUPATION Ozschililtrung

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22. UST ANY CLOSE RELATIVES Mother, Mother, Brother, Slater, Husband, Wits, Cbltdrert) WII0 ABS EMPLOYED BY ANY AGENCIES, NATIONALOR LOCAL, OP ANY GOVERNMENTEdhren Sio alb . Robes AngehOrlden (Valor, Mutter, Erode? Schwoster. Ehogallo, Ehagailln, Kinder) an, welthe bet irgondwelchen Dienststelion, on)es (Oundeststaatlicher oiler &dither Natur, Irgondeiner Re0lerung odor Dohdrdo beschdillgt end.

RELATIONSIIIPNAME Name . • VerwanduthelisgradNAME AND ADDRESS OF GOVERNMENT AGENCY

Bezeidinung end Ahschrift der Ochardo

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.......••••■•••••■•• .•••23. • MEMBERSHIP IN ORGANIZATIONS MItgnedschaft In Organisation=

IN INDICATING MEMBERSHIP IN OR ASSOCIATION WITH ANY ORGANIZATIONS UNDER QUESTIONS 23. 24. 25; AND 26, YOU ARE REQUIREDTO MENTION ALL ASSOCIATIONS INCLUDING CANDIDATURES AND DECLARATIONS OP INTENTION TO JOIN ANY PARTICULAR GROUP(CANDIDATE" FOR THIS PURPOSE INCLUDES THU 'SEMI/DER AS WELL AS THE ,,ANWAERTER • III THE GERMAN TRANSLATION). ALLAFFILIATIONS MUST BB MENTIONED FACTUALLY. REGARDLESS OF ANY RULINGS OF TRIBUNAIS, COURTS, OR OTHER BODIES TO THEEFFECT THAT YOU ARE NOT AFFECTED' BY ANY APPLICABLE DENAZIFICATION DIRECTIVES Of. REGULATIONS OR THAT YOU ARE ENTITLEDTO ANY OF THE AMNESTIES.Bel Annaba %rot MItgliedschalt odor Verbindung no ligandwelchen OrganisatIonen tinter Frog= '&4, 24. 25 und 25 mOssen Sin alle VerbIndungencinschlieBlich von Kandidonren (der Ausdruck • Candidaro • umfaill In dlasom Folio In dot dcutschen libersetzung sowohl den Acworber •als clothden .Anw4rter") und Aulnahmeanlagon erwahnon. Mmtliche Modungen Jeglicher Art mOssen dem wIrklichon Tat=siand entspreMend angeliihrtwiden, oboe Rilcksicht out Irgendweicho Entscheldungen von GerIchte% srnedskammern odor anderen KOrpercebaIlen. weld.° besagoo, doll Sic vonder Anwenclung trgendwelchor Eatossificierungsbeitimmungen .nicht betrolIce stud odor du g Sic untr . c tine der Aninestien Ial/en.

(a) ARE YOU, OR HAVE YOU EVER BEEN, A MEMBER OP, OR MADE ANY CONTRIBUTION(S) TO, ANY PARTY, ASSOCIATION.(JR OTHER ORGANIZATION WHICH REJECTS THE PRINCIPLES OF THE BASIC LAW FOR THE FEDERAL REPUBLIC OF GER-MANY ?Sind oder waren Sit. Knurls Mitglicd Irgendolner Porte), eMes Verbandes oder Irgendelnor ander= Organisation, welch,: die Grund•,sttzo des Goondgesolzes dot (Munchen Bundosrepublik =mint, oder babas Sio ha din besagurn Organisationen Itgendwalcho Zur'wendungen occia•hl? •

YESJo

NONein

I AID(b) IF SO, WHICH ONE(S), DURATION OF MEMBERSHIP OR ASSOCIATION, AMOUNT OF DUEn 01/ CONTRIBUTION'S), HIGHEST RANK OR

POSITION HELDFalls sutreffend, gob= Sic die =troll.= Organisation(en) an, din Dauer three Mitgliedsdialti=i oder VorbIndungien), die Hobs dor Gobiihreoodor Zowcndongon und den hininten innegehabten Rang, cop, din entsprechende Slanting

■Aficlir e 4 TA, E /----F

24, (a) HAVE YOU EVER BEEN A MEMBER. ASSOCIATED WITH, OR IN ANY WAY CONNECTEI) WITH THE NFL), SED, F01. VVN, OROTHER COMMUNIST-SPONSORED 011 CONTROLLED ORGANIZAT OHS OR AFFILIATES?Sind oder wormn Slo jemrde Mitglir.1 der KPD, SED, FDJ, VVN nder ..ineler kunionnnsusch gefOrdertor, Oberwacblor oder gelcnkter

Organisatinnen odor •ngognedetter laapersdiallen; stehen oder stsrdnn Sic mil dies= Organisationon In irgendwelcher VorbIndeng'odor lip n d weldiem_ Zusammenhang 1

YESJo

NoNein

I eirOR(b) IF SO, WHICH ONE(S), DURATION OP NIEMBERSIIIP Olt ASSOCIATION, AMOUNT OF DUES OR CONTRIBUTION(S), HIGHEST RANK

POSITION FIELDGabon Sin zutrollendenfalls die Dauer three Mitgliedscbaft odor Verbindung. die HOho der Beltage odor Zuwendungen und den libelist= lone-

gehabten Rang odor din entsprecherade Stellung an .

i

/ Cif T a 7/T .(:-*/cEe4(). .

25. fal HAVE YOU EVER BEEN A MEMBER OF OR IN ANY WAY ASSOCIATED WITH THE NSDAP, ANY OP ITS AFFILIATES, OR ANYORGANIZATION OR GROUPS SPONSORED OR CONTROLLED BY TIM PISDAMw.,en sic, isc.is Manned der NSDAP odor door Muer Gliede•ungen odor Irgendelnor Organisation odor Gruppe, dlo von der NSDAP1

1 gold/dart odor ..lrolllort words. Standen Sin mit dicson Orr. =nation= In Irgendolnor VerbinJung?

I YES •1 JoNONeinI

- ..... -(b) TP SO, WHICH ONE(S), DURATION OF MEMBERSHIP OR ASSOCIATION, AMOUNT OF DUES OR cONTRInUnoNtsi, HIGHEST RANK OR

POSITION HELDGob= SIG Ins suncllendon Follo die betroltondo Orgnnisktion on. die Dauer dot Mitglledschall odor Verbh.dun3, dlo HO° der Beltrkgs odor Zo-wendrurgen nod den hdrhsten innopchabten Rang, =sp. din ontrprechendo Monona

'

Ari leit T z 12.7/R E

20. WITH THE EXCEPTION OP THE ORGANIZATIONS LISTED OR MENTIONED BY YOU ABCYB, LIST ALL PARTIES, ASSOCIATIONS, SOCIETIES,FRATERNITIES. UNIONS, SYNDICATES. CHAMdERS, INSTITUTES. GROUPS, CLUBS, OR OTHER ORGANIZATIONS OF ANY KIND, WHETHER

1 POLITICAL, SOCIAL. PROFESSIONAL. EIDUCAT,'INAL, CULTURAL. INDUS:MAL COMMERCIAL OR HONOR ART. WITH WHICH YOU ARE OR HAVEEVER BEEN IN ANY WAY CONNECTED OR AS.--CIA1T4D, AND FOR BA".14 ORGANIZATION YOU MENTION, SUPPLY THE DATE YOU JOINED•Piihren Sio tinter Waglasoung dot obon venelchneten odor von Ilinen °marlin's' Organisation.= al= Parteion, Von. .e, Verbando, Gosollsdielten,Genossonichaftan. StudeatonverbIndungen. BrOdersdialton, Gowarkodulten, Syndikato, Kammarn, Institut*, Gruppon, Klub, odor andero OtganIsallo.non irgoodwelcher Art, solon Oa poinischar, ao314Ior, beruIlldies, oriIebonsrher.kullrueller. Indocirk .11or. kommenlollor odor ohrenamtitchor Natur, &nen Sin inIrgendolner Weise angebbren rasp. ongentirlen odor mit donors SW irgendwlo In Vorbindung sleben rasp. =Mandan bonen, und Mean Ste ho) (odorOiganisatIon, din Sic orwahnon, das Detour des Elonitts an

s

/1 1 '!-'' 1- /. E D OFR 11-7tO.P. A1Afivehi-E4/(Mars- OtweveR4171659.= 2'4Rre,) tig 9 1/4/W4 re

..--111314.27. IN T3113 EVENT YOUR MEMBERSHIP OR AFFILIATION WITH ANY OP THE ABOVE ORGANIZATIONS HAS BEEN TERMINATED. ETATS THE

REASON(S) THEREFORE. Palls Ihro Mitgliodsclialt odor AnglIoderung an 61110 dar onion OrganIsatIonan arloscbon 1st, Miran Sie don Grund odor•din Gran= dolor on

• .

41//741174 r. 21-44 7-A E /CA.-- as/1/0

21. (o) HAVE YOUR CHILDREN gm ATTENDED ANY NAPOLA, ADOLP HITLER SCHOOLS, NAZI LOADERS COLLEGES, 011 WIL)TARYIYESJaACADEMIES?

AnstaIt(an),

NONaln

-(b) WHICH ONES, WHERE AND WHEN? I____241

Habon Ihro KIndor Jomals elno Napola, eino do* Adolf.11itIoNSchulon, PartandbfOr•Srbulon, odor Nilliarakadernion basuditt Wald=wo und wann?

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LISTED IN QUESTIONS 33 TO 35 ABert/E1 C:1 YES Jo NO Nein 5.'Habcn SW Irgendwelche Vorwencita. dio to den unto, Plat ea 23 Ws 25 angotalulon Organisallonen oin Amt. !Anon Ring odor ninon Poston lane.hotten odor babes?

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NAMES AND ADDRESSES OP EDUCATIONAL INSTITUTIONS ATTENDEDNemo twd AnschrIlt de- besuditon Lebranstallen

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WW1 ARE PARTICUL•NAMES oF sum-

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32. REFERENCES: LIST TIMER COMPETENT AND RESPONSIBLE PERSONS. NOT RELATED TO YOU BY BLOOD OR MARRIAGE,ARLY QUALIFIED TO SUPPLv DEFINITE INFORMATION REGARDING YOUR CHAPACTER AND ABILITY. luo NOT GIVEVISC1:5 LISTED IN ANSWER TO QUESTION 35.1Rah/room: Fahren Si, drei kompetente, verantwortlIthe Personen on, die no Owen wader blutevorwandt nods voredwancrtdoes geeignet sind, befaglidi Ihrer Charaktereigenedulten rind liner Fahlgirelten trestimmta Amirante zu erteilen (reWodie tinter Frage 35 •ngeirint eind).

---i. 1NAME Name • I ADDRESS AnschrItt 1 OCCUPATION Ocechaftlgung

/Li WO.S40

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•33. (a) HAVE YOU EVER BEEN DISCHARGED Olt FORCED TO RESIGN FROM

FACTORY SERVICE?ANY POSITION

Lalstungen

FOR MISCONDUCT OR UNSATIS.NO nein YES Jo

(e) ta ANSWER IS 'YES, GIVE FULL DETAILS.Sind Sio jemele sun deer Stellung wegen 'chloride! Mom!! odor Mgenagender

- moungen warden? Falls zutrollend, geben Sio ausitihrIldw Einzetheiten so.

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LANGVNGES INauto and Indicate the latest of your edzolsatencd. I. L. Excellent . Good. P.M(Be:old:mon Sio tit end Grad Wm Flitigkeiten, d. h. •Ausgezeldinet-„Gut *, .Ausreldtene)

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' IS. EMPLOYMENT — (IN THE SPACES PROVIDED BELOW, DESCRIBE EVERY POSITION, INCLUDING MILITARY AND GOVERNMENT SERVICE. WHICH YOU HAVE HELD SINCE YOU FIRST BEGAN TO WORK.MENTION YOUR HIGrIEST SALARY FOR EACH POSITION AND IN THE CASE OP MILITARY AND GOVERNMENT SERVICE, MENTION ALSO YOUR RANK AND TITLE. START WITH THE PRESENT POSI-TION AND WORK BACK TO THE FIRST POSITION WHICH YOU HELD. ACCOUNT FOR ALL PERIODS OF UNEVPLOYMENT, AND STATE REASONS FOR ANY UNEMPLOYMENT INDICATED. USE ADDI-

TIONAL SHEET OF PAPER IF NECESSARY)Aestellungen. (Besdoelben Si. In dem dart vorgesehenen Return Jede Stellung, elnschlIeStIch Ihrer MIlltArtheustzelt end Mrs' Beamten- odor Aegestelltentatigkelt Im dffentlithen Jienst, the Sic von dem Zeit-punkt Ihrer ersten BerulsIStigkeit an Innegehaht heben. Ffihren Sic hit lode Stelluag Ihre Höchstbmoldunc au und etwahnen Si. lut Falls eines Militirdlenstes oder eiaes Offent/idaen Dieustes. tuch Mien

Dienstgrad rmp. Rang and Ihre Stellitag tesp. !Men Titel. Etginnen Sie mit der gegenwert .gen SteIlung und gethen Ste von do t surd& bli no Ihter etsten Titigkeit. Vermetken Ste Jede Zeitdauer !bier Albeit:,losigkeit und Itiltren Si, die Gtiinde far Jede angefiihrte Arbeitslosigkeit an. Benutzea Ste elnen susitallchen Bogen, falls erforderlich.)

IDATE Datum EMPLOYER AND ADDRESS OR

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NAME AND TITLE OF imNie•D

otIME SUPERVISOR OR CO.

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(1)t 35. ANY OTHER INFORMATION WHICH YOU MAY WISH TO ADD, SUCH AS A SHORT PERSONAL HISTORY STATEMENT.

Rsura 10. 9,11,10 Angeben, dl, Sle hlriztitulahon wansthen, t. B. slo inn, LebtaslanI.

37. WRITINGS AND SPRECIICSI LIST UN A SLWARAII3 SIILLI IIIR 1111.CR AND YR9O.1•11[•• 'Jr nu. rlr131.1,..,114./P•N linwri 1:0 ,1 a •-• inn r0c.:.SENT WIIICII WERE WRITTEN IN WHOLE OR IN PART, OR COMPILED OR EDITED BY YOU. AND ALL PUBLIC ADDRESSES xIADIS BY YOU.GIVING SUBJECT, DATE, AND CIRCULATION OR AUDIENCE. IF THEY WERE SPONSORED BY ANY ORGANIZATP-N, GIVE ITS NAME. II NOSPEECHES OR PUBLICATIONS. WRITS. 'NONE IN THIS SPACE.SchrUten und Roden: Miran Sic •ul einem besonderen Blatt dIa Titel und Veilener bile, von Ihnen seit 1923 bin nut Genenwail gans oder lellwalsegeschrichenen, wisammengestellten oder herausimielniniiii Vosalloililiihni.isen und olio von ninon gehaltonen ällenilithen Ansprachen nod Vatlesun3en,mit Angabe des Thomas. Datums, der Aullaiie oder Zuip ...tsflialt to I‘, IN sin COO ligendoinor OinacalsatIcn geldidest wurden, 1051en ;ie. JaenNausea an. Nos keine Roden. Ansprodion ode: 1101611.•ntlidtLIvien, ..ii • eihen Sic Oscine' lo dieso Spelt.. 7. E

30. TRAVai II' YOU HAVE EVER TRAVELED IN ANY OTHER COUNTRIES, GIVE THE DATES. DURATION AND PURPOSE OP SUCH TRAVEL IIPTRAVEL WAS IN THE UNITED STATES, SUPPLY UNDER ITEM NO. 41 AtDMONAL DATES, INCLUDING • r ypn OP VISA, PLACE AND OATS OFISSUANCE, DATE AND PORT OP ARRIVAL IN THE UNITED STATES, PLACES OR RESIDENCE IN THE UNITED STATES, AND THE DATE ANDPORT OP DEPARTURE FROM THE UNITED STATES.) BY WHOM WAS SUCH TRAVEL SPONSORED AND/0.1 PAID FORTReim: Falls Si* J =Ms lin %inland fieweson p lod, grben Si,, Zeitponkl, Dauer and Zweds dialer Ralson an. (Falls Sle In den VerelnInIen Slaaten

. waren, bitten Sin tinter Spalte 41 din tus3izlichen Annaben an, einsddi..nlicb der All, des Ausstellungsortes and -di-tums des %Ilium, des Ankunfis-datums und des AnkunlIsh. lens In Jen Veroimillen Stasieni der Atileldhallsotto,. des AbtuiSCRIWIIIS UDR des Versdullungshalens in den VeremiteenStamen,. Wer Iiirderlo dies,/ Reisen, nod wer Lezahlte sic?

COUNTRY1114 41 (Land)

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11aben Oder batten Ste 'male trocodwolcho krbrpotIldlon Dakhla odor MangollYES Ja NO Not,

OA HAVE YOU EVER BEEN UNDER TREATMENT FOR A MENTAL OR EMOTIONAL DISORDER?Sind Sto /email' wept. nelstRicr odor issollschar SION'opso In alould,st Echanillog (ie.:scot 4/(e)

Icl HAVE YOU EVER 11AD TIIIIERCULOSIS?II,(tIen Slo (corals lubmkelosal #0_

(dl WITIIIN MB PAsr 12 )4ONTHS. HAVE YOU FREQUENTLY USED INTOXICATING bEVERAGES TO EX:SESS/Iloben SI° In deo ve(psnocnot 12 Nlannteo Isa•lt j beesusthendo Get(iate ISO Els•icastl so rids nencmmcol

--- .(el WERE YOU EVE) MEDICALLY DISCHARGED FROM THE ARMED pcncEst

Sind Sl y (coals 000 bacedwelthen WebtmacbIsbebOiden ono moduinIscboo Maintop astIssloo wean? 4II) II' ANY OP •mutt ANSWERS ADOVE IS 'YES'. GIVI3 FULL PARTICULARS.

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40. HAVE YOU EVER BEEN ARRESTED OR DETAINED RY ANY Prviril. OR MILITARY AUTHORITY? IF SO, NAME THE ARRESTING AUTHORITY,me TIME, PLACE. AND REASON POE SUCH ARREST OR DETENTION, AND THE DISPOSITION OR COURT ACTION. (DO NOT LIST MINORTRAFFIC VIOLATIONS.'Rind Slo Imola 'ethane' odor lostgonommen. how. In pollsellIchcm odor ralliNrIschem Gowabloom (philters wooden/ Falls Jo. benenoon Si. die von-hanendo Bebdrelo, goben Sin Zell, CH, Giund Int Ono zoldin Yerhaltung odor elnon dexatilgeo Gowahrsam sowlo die Erlodlguog odor den Govidus-vollabion an. (Miro* Sin Woe gerlaglaglgen VerkehrsveNtbOo an.)

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41. USE THIS SPACE FOR COMPLETING ANSWERS TO ANY OP THE FOREGOING QUESTIONS, NUMDERING ANSWERS TO CORRESPONDQUESTIONS. IP NECESSARY, USE EXTRA SHEETS OP PAPER THE SAME SIZE AS THIS PAGE.!Moulton SIC dleSe Spatter, um Annocalon au don worangebeodea Pingo • i •••:..nzi,i, Nmotoetima Sin din Antwoilen la, ObareinsUzatnungFrasion. Benutzoo Sio nalgoolollc clue Manor v.o dos LloO9 dos ,•alogandeO Bogard.,

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I DO SOLEMNLY AFFIRM THAT THR INFORMATION CONTAINED HEREIN IS CORRECT TO THE BEST OP MV KNOWLEDGE AND BMW.

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