Transcript of 104-10117-10076.pdf
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14-Q0000 104-10117-10076] 2025 RELEASE UNDER THE PRESIDENT JOHN F_ KENNEDY ASSASSINATION RECORDS ACT OF 1992
PERSONAL HIBTORY BTATEMENT 1 (Appendk I)
Lsted below are names Of organtratlons Identlded by the Attorney General under bls responslbluty pursuant to
Executlve Order 10450, dated 27 Apru 1858, to Lst the names at each_torelgn O domestlc areanlzatlan;_assocletlon
movement, group Or camblnatlon aL perzons Fhlch be deglgnates a8 Totaltartan Faeckst; Communtst,9r subverelve;
cu
bavlng edopted or havlng &hOwn' & pollcy ot advoca 0 epprovlng the commleslon: 0t &cta at totce 0r rio
kence to deny others thetr dghts under the Constltutlan % the United Btates O &8 eeeklng to @ter the torm o
gavernment of the Onlted Btates 67 uconstltutlonal meana
Each appllcant or employee and eouse (LLanp) must rarler the-tallowlng lst ot areantratlona tar certlicatlop
purposes.and &gn: On" the last page
Abraham Llncala Artedo postoa. Bcbool {0r Markt 0tudlet-Botton Mumnebusstd
Abrahem. Llpoala: BcboaL Chlceso: Illnob Erldset-Bobartoan-Bchmldt.Dafedso Camnittod
Actwon Comndtted @N0 Bpatd Nov Bulgarkan Amartoan Poopkt Latgua 0 tpa Oolted'Bet 0
Alebams.Feoplata ptuoattoual_ Anoctlon (60 Communbt Polltf- Amarlaa
E Qacda) -
Ametcn meebtan. tr Roconstructto D Yugoalsna . IDc Clarnla rmanvency Dalenod Oxmmitroo
Amertcm Bfanca: 0t tto Redaradan' 01 @roar Marldmo Onlont cultorab LabaL BabocL Ia,-DI:Dlriadaro Bttdot,-Ban Prancleca
Amartcan chrdsttan Radonallat Pary Caltorb
Aneriex: Omlttd m Luopteu Rarterr Rellat (680 Bockltnt Cumpatto-quekan- Feopbb Boclou]
Fota BmWT) Oent. CouncMl 0 Amerkean: Wamad & Croatad Deroedl 09
Amerean Gonmlttaa fr Euteatani QI melo Bm bo 0 Cent Oc' a Amertc Doatad Woncn Ro-
Amarten Cnmltttoa tar Bpanlah. Beodam tonat cmncl q.@uathan: Woan: Analen Commlttedme LbaBettemant 6[ Jora [n Buphldlen, Ine OentaL Jennod: Amtoclattn (Belttu: Oha Mppajld: Eel)
amexlcaa Onttteo &r Yugoasr; BAlet,.Da; catt Jpnen Arodttto: & Buttee: Culttaruks_
Amatona cammlttoo #BunoT LaborCondltons:l Droro Ott Ornletkn: 0t tt Ounn-Amatloan Nedonn' Allanoa
Amerdbn CanallfurL Damooratla: Otere [orerty tom % tbe (Daueabo-Amerlkanleato Enbelanrunt)
Gnx bate: @nuncl;: Gadt Amurtan: 0nnltte t Ne
Cuventabuma &clol}] donu: Ontb
Anertn caunal: 0 Bolet; Ralotlons chlos. Wzaldare Aptat; Dc
Amerbun Cmatlan Cmrd Chopin Oulturel Crntet
Anetoan Jould Ldur cuncll clittOnlttea-tr BIT Hridem
Amerlcen Lasua Aalnd WuIna Rcm attlam Onnlttra:at' t0o Wpper*W7ott-Bldo (Nov Jot Glby)
aaln Lmua Dr Perro and' Domocdd] otm comndtto 0 Bo xud Borde
Amatan. Natonn [dtr AtYJ Citeean Eersenaj Dalans) Cmnturtne
Amertcan patlanrt Bctallst Letgus Olttans Protratlro Linrud
Amertca Ratlana! Bochllst Eubz Olt:Lberttor Bponrartr Conmltteo 0 Plttebureb
Amartcan Ratlonallst Paurtyy Oiu Bld Cnrea end10 AQlbsted oeantaattons. Includlng:
Amertcan Ferlot4 Ic ClrD Eledb cma Ior Ta
Amaricn Fenco Ornndo Voterans Asalnrt Dlactrtmtntlan_ obt: Eletu Coara q
Amerkcan Feeco Moblleadon Rov Yorr
Amarlaan Eales t0 Ebaoe Cln Bkehta Cangreea. frTetao (6e0 Clru Elehes Cangee)
Amerlenplla Labar Oxunch Cdlumbtans
anekan Pollab. Leagua cmlto coordtmdor- ETo: Bepublcs Epanala
Anertcn Recuo Elp Mladon (0 project 0 tbo Onltod Amarkeao cmlto Pro Dercbos Onved
Bpankah Ald Committeo) (Be4: Fuarto Elaan camlto Pro Llbartades Clres)
Amertcap-Rualan preteral. Bocloty Committea {r Damocratlc Par-Eastarn' Rallcj
amertcan Buealan. Iotjtuto; Nov Yort, so:*oow 0 tbo Amon - cmmlttea f0r Canstltutlanal und.Fallttal. Freodod
Cd Busslan Insttuta Jor: Cwtr Reltlons Mt tho Boriot Cammlttos.fu: Rataelkt Artlon
Onlaa cammlttoo [0r Peaeo ad Brotherboad Poottval Ln PhUadelpbke
Amertcan Buaden Dstltut;. Phlladelphb cmmlttoo {0rtb Detends aI tho Plttabwea- @lr
Amertlcan Buedan Istltuto 0t Ban: Eranckoco commltteo fr; tha Nee [n tho Arto
American Buedleo: Insttuto & Bouther Callorla Loe Angeloa Conmlteed {O tp0 Proteotlon.0 tho BLU @t Eght
Amertcan Bsr Cangred camnlttoo tr Wand Youta; Mendehlp and Cultun brchange
Amercan Momen I Faco cammltteo 0 Abolkh Dkcdniatton 0 Marland
Amarkcan Youtb-Cungera (Be0 cngtor Asalnst. Dlocrimtaton; Margladd Conger
Amerlcan Youth {0r Democracy Anlnst Dbcrtmlnatdon; Prorldonn comlte 0 Abolbb
Armenlan Progerdlvo Leaguo 01 Amoric Dbeintnstlon b the 8tw @ Maryend)
Acoctated Elans 0r Amertca cmnlttoo t' Ald tho Elghtlog Bouth
Asocbttm 0r dorels Elans Comnltta W Deend Marlo Elchgrdo
Anockstlon 01.Oaren' Hetlonelo (Batchodautcho Varalnleung) Comnttod @ Dafand t0 Eldu and Ptecdom 0I Plttsbureh
Audand-Orentndon Qar NEDAP; Orare: Erancb 0I Narl Party Rlltc Frkmen-
Onmltres t Opbald tbpa: BW 0 Blebto
commonvealth Callese; Mena atanes
Batmor *nd
Darm Ereedam cmmlttoo oommunke Farty;_ 0. 8. _ 4 Je wubdlndlona tubaldlar1as, @d Banjentn
pbeer Deeon Boalot] amibatar
PORU 444d de PRETIO0B @DITTONB 1 11*
380 1 XN Rtr"
dog
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Oommuala putkaa Ausocbtla tu Mubdlmoon' Nbaldlarke4 Indopopdcnt Pooplot Put]
and A@lbate Includlng: (Be0 Indopendent FurtJ)
Lbaos Peoplas Educatlond Aeocbtton ndustrwu Worterd 4 po Worla
Nortds PUD ad Educatlonai Leaquo Itarauonn Labor Daanso
Otlobams Lanuo {0 Rolltau tuaaton Intraton l Worten Ordet, 1u @bafrtdona uubeldturle ed
Pooplot Educatlonal Ind Prod Aeocbtton & Tary Jleat
wvtlnu Laguo for Poople Iductoo Jopanero Arocatton 0 Amerco
Dnd# Agelnn Dbarlnlustlod Jepanoee Otetoems Cenuu Boclety (Enlgu Dobo Obuo Eu)
(Br Ommltteo 0 Abollab Dberlmlnatton b Murlnd) Jopaneao Oteteets Courentlon Tobyo Jopan, 1a1
onued & Amakean Revalutlanar} Wnter Jopanoeo Protoctr Aeocktlon (Bocruttns Orantndoa)
ooaner 01 Amerlean Womed Joterron echod a Bctal Bclonoo Nov Jort Olb
0nnu 4 tho Onemplojed Jovtan Oulture Boclet]
Conneotlcut Ounmitleo 1 Aa Vktlms 0 ebo Bmjtd Act Jovkeb Peoplot commtted
Ondectcut Btato Yout Conleterco Jowtan Fooplo Pretarnal Order
oud {0 Jobl Relle apd Houdn8 Juroru Ilakal (Tbo Oxmmllloe {aT tbo Crkects)
0nc I PAn-Amerkean Democngy Johnoon-Porest Oroup
cudcl & 0rat Amertead Jobneonlees)
Dowdc 0 ataan Auun Jonnoonlte
Codtan Benovolent Proterlg] (Beo Johnoon-Fotest Otoup)
Jolne At-FPascbt Refuged Commlttee
DU Nlppon Butoku Eal (MIearJ Vrtuo Bocloty &t Jopan @ IQU- Jolot Ooncll @f Progreadivo Itallan-Amerkcana Ine
tn ant 8cot] 4 Jopad) Jooepb Wedemoyer Bbool 01 Boctal Bclenco BE Loula Hlaour1
DADJ Vorter Ptrrs Cub
Denbob Duleneo comnltted Elba Balnen Ea (Asocbton 0t 0. 0 Giticodd QI Jopadese A-
Dadl Aletlerd bclog] (Lrgtocd 107s add 1a1d) ceott] Gbo bro retuned 0 Amerkce uter studjtn{ @ Jepan)
Donab Daledgd Cammlttea Knlehb a t6 Rnw Camalk
Dotralt Youth Anembly Eu Eur Ea
Eyoueer; 0ks9 Xnor 1 Emheuer)_Letbra (Eteeueer
4ust Baj Feace Oummlteed Dund). Eythaoueer Pellorhlp (Eytsouser Enmerdachafe)
Deporo Progterlto Leabuo Eymaousar We Rallef (Eytbsoueer Erleahlfurert)
Durud Clutod 0 Baro Bpankah Bafugeed (Toundlng bodj
4 W0 Xort Amarlcan Bpankeh Ad commlttee)
Dverybotr1 Omnitea & Quu9 Far Labar Councl Ior Nea0 Elehu
Ibat Bereatoh Aoochton Inc
Pamdlo 01 tho Baltlmoro Bmlth Act Vlctlms Labot Youth Leebuo
Pamdko 0 tho Enltb Act nctlms Lesuo Ior Camman Benad
Roderto 0 Italkn Wu Veterans t to 0. & 4 Ine (Anocto- Leasuo OI Amertcan Mntero
dua Rerlon o Ombattent ItllanL Nedenadono degtt Bta& Lktor Bocloty (Itallan Blcr Ebtrts)
DOnld tAmerke )
ylobb-Amerkcan Vutun Ald Bocleb] Macedanln-Amerlcan Peoplot Leaouo
Nortde PerJ and Educatlonu Leaque (1o oommunlst PoutleU Marto Norguntlnl Ckrdlo
Anocbton) Martmo Labor Commlttod t Delend 4 Lnnon
rroderter Doudlers Educational Centor Maryland Cnger Asalnst Dkartmlnstta
Foedom 8ta8e; IDc: (Be0 Committed 0 Aboltah Dbertmlnstod b uurykand)
Irlands 01 &5o Nev Oennanj (Ftoundo dos Nauen Deutachlanda) Maaachnsotty Commtted Ior to BW 0 Blgbe
Eriends 0I tho Bo710t Oplod Mucbuetts Mnub Woten {Qr Feaco (Dot condeceed Mtb tb0
Wlpute Tomed 0 tho 0. 8 4 Ic)
Olrbaldl American Frateranl Bocleb} Meurkco Brarerman Defened Cammlttee
Ooor3o Weahlngton Cuver Bchool, Nem Yort Clty Mlchlgan Glw Rlstts Pedertlon
Oered-American Bund (Amerttadeutscher Volksbund) Mkchlgan Councl for Peace
Oerman-Amertcan Republlcan League Utchlgan Bbool 0f Boclal Bclanca
Oerman-American Vocatlonal League (Doutche-Amertankacnc
Beruteremelnschalt) Nenta Telkoru Ounrudan (Imperlal Muan] Mrlends Oroup 0
Ouardtan Club Bouther Calornls Rer Veterans)
Trade Oploo Counch Natlonal Assoclatlon 0f Merlcan Amcrlcans (0leo knowm 48 Asocbs- Eurlen
Dreu Clvh Ubertles Commitled clod Neclonal Mexlco-Amercana)
Eetmuena E4 akbo *Ow 41 Nokubel Helebl Olmuahe Kal Zuibol Retlonal Bluo Btr Motbers 0 Amerlc (not t0 bo COnfused M1tb
NbonJln, Helyeku Olmuaba Kal and Zalbel Betmuabt En (Jop- tb0 Elue 8eatr Motbera of Amerlca oreanleed Ln Pebnury 1843)
anceo Reddln8 m Amerkca MIlleary Conscrtpts Aesocbattlon) Natlonal Ommltteo fOr Preedom 0 Uho Pteds
Erotherbood Nettonal Comnittet IOr t0 Defee) 0 Polltcu Prlooner Eelenlc-Amerlcan
Elode Etl (Imperlal Japaneso Reservlsts) Netlonal Commltteo W Wip Amnesb} Ir Bmltb Act Vkttms
Ionar Ka (Rlatng 8un N8 Boclety F= BToup OI]Jopaders Ratlonal Commlttea W Mbn the Peec)
Natlonal Conferenca 00 American Fallg} Ln Chlna apd &ho Far Eaot
Mo Telerang)
Hokubel Zalgo Bbote Dan (North Amerlcan Reeervo Omcer 1x (e Conlerenco called by tho Commltted Ior Democrauc Ru
Bastern Pollcy) caton)
Mrtero MobUlation Ior Defenso Natlond) Councu 01 Americans 4 Croatlan Dexcant Eougarad-Rmectcar
Coudcl Ior Democrcy Natlonal Counct OI American-Borlot Frlendabtp
Natlonal Federatlon Ior Constitutlonal Llbertled Huogarlan Brotherbood
Natlona Labor COnlerence IOT Peaco
Idabo Pendon Onlon Natlona Negro Codgters
Independent Party (Beatue, Weahlngton) Natlonal Negro Labor Councll
(Bao Indepcndent Peoplott Purty) Natonalbst Actton Leeguo
~2 4
(820
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Bwu Barbere Peece porm
Neglodallst Pantj 0 Puerto Rlco Bonspped Delense Commlttee
Rotucd Iriend q Amertca (dnco JDJS) Bchnaldaraa-Davy Dalenro Ommlttoo Netao Labor Vlcton Commltter eobol 0f Jorban Btuder Ncn Jort Clg Ro= Commltteo IOr Publlcaulons Batuo Labor Bchool, Bentuo, Weahlaston Ntchlbel Eogyo Ealabs (Tbo Ortat Pu Tbeatit) Berbbn-Amertcan Pralernal Boclob]
Norta Amertean Commltloo Ald Bpankab Damocr9 Berblan Vldordan Coudcll
Nottd Amertcan Bpanlah Ald Oommltead ennto Temple (Lmttod 8tt Elnb sboltabez b IALs)
Norts phlladalphb Forun Olver Bhlrt Lilon 0t Amulcs
Nortberr Jopldera Aspocbtlon @ric cuncl 0I butber Cultorb
Oovet Wortero Bocloty
Oblo Bcbool of Boclal Bclenced Uorenln-Amerkcen Natonal Qouncu
otkatom Committed 1 Defend Folltlcal Prteopen Bochelbot Warkerd PartJ, Includins Amortcan Oxmmlttoe tor Buro-
Orbboma Letgue
{or Follttcal Educatlon (e8 Communlst Pout-
Pead Workervt Balle
E4 Anocbtad) Borotu Ey (Potherland Bocloty)
Orledn } Bouthern Hlant Lncarporated Boutber Negro Youtb Copger
Bulro Bho (Bepetvo Oflcen Aseoctatlon Loa Angoled)
Pecldo Nortbwest Labor Bebool Bestuo; Weahlastop Bytecuea Womon I0 Pa
Po Nt Feao Club
Ferudo del Puoblo 6t Fanamt (operattns ba tbo Oanal zopo) Tom Paldo Bcbool 4 Boclal Bcleneo. Phleddlpbka, Pannorranb
Fesco Intormatlon Center Ton Paldo Bchool q Restchester;, Rev Yot
Futo Movemedt 0I Ethlopb Tredo Dnlop Connlttoo Ior Fetoo
Feoplod Di5n Ie (B0 Trado Onlonbsts Ior Penco)
Feoplot Educatlonal and Fuceo Acsoclatlon 01 Toru (1 Ommu- Trado Tnlonbsto I0r Penee
plst Roltcal Asooclatton) (Bea Trodo Onlonbst {0 Feleo)
Feapket Edueatlonul asocbtlaa (Lnootponted nnder Damo L Tr-Btato Nogo Tredo Onlan Ouncl
Educatlonal Aosochttol Ie); ao mo 0 Fooplop Aaueleeons} Cebto:} Foplo; Onlverat6y. Pooploo Bbool
ottk-Amertcan Pratery Onbon Pooplot Inoueute 0I Applled Rellgdon
Proems (Beatte; Weablngtop) Dnlon & Amertcan Oroattads
Poopler Onlon & Revv Yor Veterads Fooplo t Eadlo Poundsdlon, Inc: Atd Cammtted Onlted Amerlean Bpanto Peoplo? @lob Fart] Onlted Commltted 0t Jertsh Bocktte ad Lndomanachatt rod- Paluadelpbbs Labor Commltteo for NegrO Rlepta
Qor 8 coordtnaton ommltted 4 Jorun Fplladelphla Bcboal 01 Boctal Bclance ad an eratons 0co
LandamanachaI6ed apd rrlera Orbanleatlops
Pboto Lesbuo (Nov Yort CIGJ)
Onleod Commlttee q Butb Enc Amerlaan
Httsbured Art Club Dolted Dendo Councu a Boutnerd Calttorba
Ralueal Prboonarv Wellaro Committeo Oplted Bariem Tonwdt connumen Orraniraton
Rlonb Bo-of 0 00 IWo
Oaran-Amerlcan4 Ubo Jor Progteedlro 06- Onlted Moy Day Commltteo Progeentvo Onlted Negro end Allled Veterans ot Amertc DAp-Amarleans 0t Calcabo
Fraletarten Parby 0f Amertes
Protestant Wer Votarens 0I tbe Dnltod Btatea Inc Peterans Agelnst Dkocrlmlnston 0 Oln Blehes Oongters at Now
Fontalonal Commltteo 0I Oltkeopo IOr Peace; Boutbwost 4O Yort (60 Civu Elgbts Conger)
Brortdon Cmmltleo 0 Laun Amertcan Afetr Veterans q *0 Abrham Ltncoln ertgedo
Portdonal committeo 6 Abollab Dbcrimlnatlod b t0 Be6 0 Vuelnlo Leaguo Ior Peopleo Educattan (0e0 Cbmmunbst Polltleu
Marylana Aeooclaton)
(Beo Commltted 10 Abollah DlcrImlnstlon Ln Maryland) Folce 0 Preedom Commlteee
Puerto Rlan Comll Pio Lbertades Clrlle (CLC)
(Beo Comlto PtO Derecboo Cltued) Rujt wbltoan Bchool 0I Boclal Bclence, Nowvark, New Jereey
puortorriquonoo Onldoa (Puerto Rtcans Unlled) Waahlgtop Bookabop Agoclstlop
Weahlngton Commltteo Ior Democratlc Actlod
Qusd 6lby Oommltted {Or Peaco Waehlngton Commlttee 1 Defepd ebo BW 0 Rlgbts
Queonsbridgo Tonant Leaguo Waahlagton Commonweallh Federatlon
Weahlngton Pendlon Onlon
wlaconald: Confarencd 0p Boclal Leeislatlon
Bvolutlonar} Worterdo Leaguo
Rorter Alllanco (dnce Apri 1933) Romanlan-Amerlcan Piternal Boclotj
Buodlan Amariean Boclety: Inc
Ylddlaber Kultw Ferband
Ed (Patrtottc Boclety, 0 Chery Assoctattop R compoaea Toung Ommunbst Leabuc
Btura Yuboalsv-Amertcan Cooperadlro Hame: Inc
4 Toterans 0I Bucco-Jopadedo We) Yugodlav Beamen Club: Inc:
Bamuoi Adams BehooL Booton: Maaaachusetts
3
+$0;
and
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This DATE (PIli b) Do Not Use This SPACE
ISSUEd By PERSONAL Histor Y STATEmEnT 1961 September 6,
INSTRUCTIONS
1
Answer &ll questions completely o check appropriate box: If question is not epplicable, write *NA'_ Write "Un-
known
only1f you d not know the answer and it cannot be obtained from Personel records. Use blenk space at
end of form fOf extra details on ay question for which you have insufficient space
2.
Type, print or write carefully; illegible or incomplete forms will not receive consideration.
3. Consider your answers carefully . Your Signature at the end of this fom will certify to their correctness Careful
completion
of all epplicable questions wiil permit review of your qualifications to the best advantage:
SECTION GENERAL PERSONAL AND PhysicaL DAA
FuLL NAME (Laat-Firat-Middlo) 2. AGE 3. seX
FLORES_ Dantel 26 XMALE FEMALE
heiomt 5. weight 6. Color Of EyeS 7. Color Of HATA 8 Pe Complexion 9 Type BuilD
5' 8" 165 pds Browm Black Dark Medlum
I0 SCARS (Typo and Locatlon) Right cheek, one-half Inch soar; lert upper Ilp , 0ne-
quarter Inch_scari both
received_pleying football
Other Distingushing PhYSIcAL Features
None
12. current AddresS (No. Stroot, City, Zonc. Stato and Country) 13. PERMANENT ADDRESS (No., Stroot, Clty, Zone, Stoto and
Country) AND pkone NO.
2828 Connectlcut Avenue ,N _ #203 _ 2828 Connecticut Avenue_
9
N_ W
Waghington 8, D, C , #203 Waghington 8, D,C,
current PHONE no. 15. office Phone NO. ExT_ 16. LEGAL RESIDENCE (Stoto, Tenttory Or Cormtry)
265-8322 05 None_ Waghington,_ Digtrict of Columb ia
17. NiCKNAMES 10. Other NAMES You HAVE used
Dan None
19_ INDICATE CirCuMStANCES (Includtne Lensth 0l Timo) UNDER which You MAVE Ever used THESE MAMES.
Pergonal_acqua_ntances twel ve years
20. IF LEGAL ChaNGE, give PARTICULARS (here and by What Authorlty):
NA
SECTION II Position DATA
INDICATE The Type Of Work Or Position For which You ARE Applying
Any of communic ations; administration; or pergonnel
work,
2.indicate The Lowest AnmuAL Entramce SALARY You will 3. DaTE AVAILABLE For EMPLOYMENT
^ccept (Yos Mlinoi bo conbidorod 1or,73porition wvith 8 lotor
ontfenco calary): 4250,00 Imediately
indicate Your Willingness To TraveL
OCCASiONALLY AFREQUENTLY constanTL Y Other:
5. imdicate Your WillinGness To AccEpt Assignment IN THE FoLLowing LocaTions (Chock (X) oach Item oPplicablo)
WaSHinGTON, D.c AnywheRE In U.3.
CeRtaIN Locations ONL Y (Speclly):
outside continental U.3
6. iNDicate WMAT RESERVATioNs You would PLACE On Assignments outside TME WAshington; D.c. AreA_
I wuld be willing to travel within the Unlted States provided
eafd travel would not involve 8 permanent move whereby my le gal
residence would be changed _ However, It 18 my, W sh to live oversea8
on a
permanent babi8 .
Form 444use Previous Edition_ 1
Y9
11-50
HIOY COOHEY
F'&
phage
s/n
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SECTiON' |ii Citizenship
DaTE Of-Biath 2 placE 0f D1RTH (City, S1t0, Coulry) preseNt citizenship (Coutry)
ugust 4)1985 (0_(an Marcos Texes_ Wntted States of America_
Acquired By TE Natural" 6. NaturaLization certipicaTe No. 04 Citizenship ZED
X Birth Marriage OThER (Spoclly): NA NA
court IssuiNG NaTuralizatiom certificate 0_ IssueD ^7 (City: State, Cotntry)
7,
NA NA
9_ HAVE You HELD previous nationality 10. if Yes, GNe NAME OF country
NA
YES No
Give particulaRs CoNcERNing preVious Nationality
NA
13. GIVE Particulaas YES
12. HAve You TAKEN steps To CHANGE
presENT citizenship No NA
For U.. Citizenship Vhat Is PrEsENT status Of Tour Application (Fico( Paporo, Etes)?
You MavE Applied
NA
16. Port OF Entry 17- ON passport op What COuNTRy
15. date Op Arrival in U.3.
NA NA NA
19_ DATE ViSa issued
18. LAsT U.S . VISa (No-, Type Placo 0l Io8uo)
NA NA
SECTION IV EDUCATIOn
ChecK (X) Highest LEVEL OF EDUCAMON ATTAINED_
Over Two YeaRS college No Degree
Less ThaN High ScMool GraDuate
BAcHELOR's DecREE
High JChool GRADUATE
commerciaL sChool GraDuaTe GraDuaTE sTudy LeaDinG To Higher DegREE TrADE, Busine9s. Or
KaSTeR'} DeGREE Doctor'8 DgREE X Two YeaRI College Or Less
2 ELEMENTARY SCHOOL
NAME 6f EKEMENTARY scaool 2 Adoress T@0 Stto, Country)
(an MafcoslElenentarySchool Gan Marcos Texas LASA
TATES ATTENDED (PromandTo) GRADUATE
Septu_1942_ MaXy 1951 X YE} No
3_ Kigh SCHOOL
2.ADoREss (City, Stoto, Country)
NamE Of SchOOL
KGan
T9zgo3 High
School (an Merco8 Texas, U,S,A.
03 DATES 7TTENDED (From-andTo) (0 GRADUATE
Septo,1951 Max_1955 X YES No
Name Of Kigh ScHOOL 8. Addre3s (Cty; Stato, Cormtry)
NA
Dates ATTENDED (FomtandTQ) GraDuate
YES No
COLLEGE Or University Study
subJect DATES ATTENded DEgREE Date BEmiatr
MAME ANO LocaTion Of CoLLeGE or University To REc'D AEC'D {o9f
Major Minor From
SECTION IV CONITINUED TO PAGE)
52
6lf
0p
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SECTION Iv CONTINUED FROM PAGE 2
GraduaTE Degree MAs BEEN Noted In Item Which Required submission Of A Written Thesis, inDicaTe The Title op*The TMesis AND arieFLY Describe Its Content.
NA
TRADE, COMMERCIAL AND SPECiALized SCHOOLS
Mahe And ADdress Of SCHOOL Study Or Specialization From To Months
NA
ZHLIARY TRAINING (FuLL Time Duty I SPECiALIZeD SCHOOLS Such AS ORDNANCE, INTELLIGENCE, COMMuNiCATionS, ETC)
mame Ad Address Of SCHOOL Study Or specialization From To months
Merine Security Guara
Scboal=
S
Henderson_Hall
Merine Corps _ Security Guard
Nashlngton 25,0 c _ Training 9/28/58 10/31/58 (5 w
Other EDuCATIOnAL TrAininG Not imdicated Above:
Weepons Tralning In Merine Corps _
Acted a8 partisan during cola weather training at Bridgeport,
Calffornla (Pickle Meadows USMC )
SECTION V Foreign LANGUAGE ABILiTIES
COMPETENCE IN ORDER Listed
1. LaNGuAGE How Acquired R-Rood, W-Writo, S-Spook
(Llat bolom oach laneue8e In
which You Poooo8e any de8roe Equiv- FLUENT
0[ codipotenco. Indlcate yout ALENT But ADEQUATE AdeQuAte LimitED Pro COnTACTIACADEMiG To 0b ViouSLy For FoR KnOw- NATIVE Study Proliclency t0 Road, Write or NATIvE FOrEIgN RESEARCH TRAVEL LEDGE 0f LONGED (wIth
Speak by Placlne a chock (X) FLUENCY Country RES- parente _ le(318)
IDEncE etc.) In lho epproprlato box(0e): R # 3| R A
Spanlsh X
2 If You MAVE CHECKED "ACADEMiC study UNDER "How Acquired indicate LENGTh AND INTENSIVENEsS Of STudy
NA
I7 You HAVE indicATEO pluency For LANGUAGE HAVing signipicanT Difperences in SPOKEN AND WrittEN Form; Ex-
PLAiN Your competence Therein_
NA
DEscRiBe Your Ability To do specialized LANGuAge Work involving VOCABULARIES ANd Terminolog Y In THE SciEN-
Tific, ENGineErino, TeLecommunications; Military, AND Other Specialized FiELDs.
Coula act 48 l1teral interpreter e t almost any level .
ip You HavE Noted propiciency iN Language WOULd You BE Willing To Use this Ability IN ANY position For Which
You Kight bE SELECTEDT
YeS No
3
Hq .
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Page 7
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SECTION Vi GEOGRAPHIC AREA KNOWLEDGE AND FOREIGN TRAVEL
List BELOw ANY Foreign UoREGIori8 OR countries In Which You HAVE TRAVELLED Or GaiNed KnowLeDGE as 4 ResultOf
Residence,Study or AssigNL ENT , indicate Type of KNOwLEDGE Sucm As Terraim, harBoRS, Utilities, Rail" RoADS, industries, PoliticaL parties, ETC:
KNOWLEDGE Acquired 0Y Dates Of Reqior3e 8ountry 8peiAL,zeB RNOwLEDGE RESIDENCE Dates AND Work zed Or TrAVEL PLaCE Op STUdy RESI- assigm DENCE TrAVEL Study MENT
11713758
Bollvie General kewledge_ 17444660
to
Per
General_knowledge -11/20/60 X
6716759 to
Cht le 6/21/59 X
6721759 to
Argentina 6/30/59 X
6/30/59 to
Drenway 72[59
2 INDICATE The purpose OF Visit, RESIDENCE , Or TRAVELTR Each Of THE REGiONs Or countries Listed ABOVE.
Marine Security Guard American Embasgy Bolivia and Peru
Vacation Chile ; Argentine; Uruguay; Panama
3_ United StaTes passporT Number AND Expiration date, if ISSued:
0 No-674850%sP-85575
Pagsport ba 8 been cancelled.
SECTION Vii TyPing AND STENOGRA?HIC SKILLS
TYPING (WPDQ) 2.SHORTHAND(WPN 9. SHORTHAND SYSTEM Used Check (X) APPRopRiAte ITEm
45 wpm None GREGG speedwriting STENOTYPE OTHER (Spoclly):
2 indicate Other 0usiness MA chines With Which You HAVE HAD OPERATing EXPERIENCE Or TRAIniNG (Comptomotor;
Albbo8rph Card Punch; Etcj) _
Thermofax, mimeograph, swltchboard
SECTION ViiI SPECIAL_QUALIFICATIONS
1.List ALL Mobbies AND sports iN Which You Are Actie Or HAVE activelt PARTicipATED: indicate Your Proficiency
In EACH;
Foot ball good
Besketball fair
Swlmming ~good
ReadIng average
Contract.Bridge
very
2 INDICATE ANY SPECIAL QUALificAtions RESULTInG FROM EXPERIENCE OR TRAining Which Might Fit You For A ParticuLar Position Or TyPE OF Work_
None to my knowle dge
Excluding 0 Usiness Equipment Or MACHiNES which You MA Y HAVE Listed IN iTem ?, secTion Vi, List AnY SpEcial
You Possess RELating Other Equipment AND MACHINES such operation Of SHORTWAvE RaDio (Indt E*888
calo opood; bendbe &nd
A82sein8,-
offset press, Turret LAThE, scientipic AND professioNal devices.
None
SECTION,VM CONTINUED TO PAGE 5
52
Um
good
As
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Page 8
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14-00000
SECTION VIII CONTINUED FROM PAGE
ArE You Now OR HA VE You Ever BEEN A LicENSED or cbrtifiEd Member 0f Any TRADE or ProfEssion, Such As picot, ELecTriciAN RADiO OPERAtor, Teacher, LAwYeR CPA, Medical TechniciAn; Etc.?
CJYes KJno
IF You MAVE ANSWERED YeS To ABOvE, INDIcATE KiNd Of LIcENSE AND STATE ISsuinG LIcENSE (Provide Liconde Reeietry
Nuber, M kown:
NA
First LICENSE OR certifiCATE (Yem oI Jooue) Latest LIcENSE OR cERtificate Yor 0f [00uo)
NA NA
List Any SignIficANT Published MATeRials Of Which You ARE THE Author (D? NOT aubmit coploo ulooa roqucotod. INDIcATE The Title; PubLicATion DATE, And TTpE Op Xriting (NonrFiction 6r Sclantilic articlee, Gonoml [ntoroet oubjocte, Novoib, Short
Storiot, Elc): J
None
indicate AnY Devices Vhich You HAVE INVENTED AND STATE WheTheR Or Not They ArE PATENTED
None
10. List public SPEAKING AND Public ReLaTions EXPERIENCE.
Eave spoken In my fether'g church and other churche8 epproximately
150 tlmes. Met and a881sted public in Enbagsles during my tour Of
duty_ with the Marine Securtty Guard
List Any PROFESSiOMAL ACADEMIC or HONORARY Associations OR societies In Which You Are Now or WERE FoRMERLY MembeR: List AcAdeMic Hongrs You KAVE RECEiVED:
None
SECTION IX EMPLOYMENT History
NoTe: (LIST Last POSITION FIRST ) Indicate chronologicdl history of employment [6r pabt 15 yeare. Account for all periodo
tacluding cagual employment and &Il periods 0f uemployment . Give addres8 and 8tate whal you did during periodeol
memploymtent. List ali civilien employment by 8 [oreign Govemment, regardles8 o dates_ Ln completing item 9, "D- ecription ofDuties- casider you experience carelully &nd provide meaningtul, objective gttement8_
incLusive DATES (From and To By Mo_ and Yi ) 2 NAME Of EMPLOYNG FRM oR ^GENCY
Pron 1949 to 1953 E)Zburn!slDrug_Store
AdoresS (No-, Stroot, Sbto; Coentty)
(San Mercos Texas
KiNd Of buSINEsS 3. NAME Of supervisor 06
Drug_Store Mr WLllien (H1llburn
Title Of Job 7 . SALARY Or EARnINGS 0. CLASS. GRADE(It Federal Servico)
Fountainattendant__ '100 00 PeR month
Description 0F Du Ties
Employee at goda counter
10 . REason} For LeaVing
To participate In scbool 0vents (football) .
SECTION IX CONTINUED TO PAGE 6
53
3 Wi
city'
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Page 9
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14-00000
SECTION Ix CONTINUED FROM PAGE 5
inclusive DATES (From and To By Mo. and Yr.) 2 Name Of Employing Firm Or AgenCy
July1954-June_2955 Diamond Grocery Store
3 ADGREsS (No:, Stroot, Clty, Stto, Country)
SouthGuedelupe_ St San Marcos Yexas
Kind 6F 0UsINESS 5 .NAME OF supervisor
Grocery Store Mr _ Ignac 10 Gonzales 06
Title of Job 7. SaLARY Or EARNINGS 0. CLASS. GRADE (II Podoral Servico)
Butcher 530.00
PER week
Description 0f Duties
Slaughtering and preparing meat for sale a8 well a8 actual sell1ng.
10. REASONs For LEAVINg
To attend colle ge
inCLUsive DATES (From and To By Mo. and Ys-) 2 MAME Of Employing Firm Or AgenCY
Meys1955 September .1956 (San_ Marcog Baptist Academy
ADORESS (Noj, Stroot, Stto, Country)
San Marcoso Tezas
KIND 0f BusINesS 5 NAME Of supervisor
PrLvete_ School Mr. (John_Sparkman 06
Title Of Job 7. SALARY Or EARniNGs CLAss- GRAOE (IL Fodoral Sorvlco)
Painter's Agelstant 35 00 PER week_
9 DESCRiPtioN 0f DUT IES
PaInted dormitorles In the Academy
10. REASONS For Leaving
To attend s chool
INCLUSIE DATES (From and To By Mo. and Ys,) 2. MAME Of Employimg Firm Or AgencY
Septenber,_1956 1957 @Economy Department Stores
J . Address (Noj, Sttoot, Steto, Comtry)
(San Mercogo Texes
Kind of BusINEss NAME Qf SupERvisor
Clothing Store Mr _ Max_Mendlovtz
Title 9f Job 7, SALARY OR EARNINGS CLASS. GRADE (Il Fodoral Servlco)
Seles Clerk 30= 0o PeR wee
DescRiption OF duties
Assisted cus tome rs In selecting and buying good8 _
10_ REASONS For LEAVing
To Join the Marine Corps .
incLUsivE DATES (From and To By Mo. and Yr.) 2 NAME Of Employing Firm or Agency
July 2651952 July 25 1961 Unlted States_Martne Corps
3 ADDRESS (No-, Stmot, Stato , Country)
MarIne Corps_ Schools Quanticoo VirgInie
KIND of business 8 NaME op supervisor
Mlltery Col John_Magruder_
Title0f Job 7 SALARY Or EARninGs CLAss. OrADE Podoral Servlco)
Maripe_Corps Mugeum Attendant I80 .00 Per month Cpl (E-y)
SECTION C CONTINUED TO PAGE 7
5&
lr
city'
Julye
city,
Cuty,
(It
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Page 10
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14-00000
SECTION IX CONTINUED FROM PAGE 6
DEscRiption Of DUtiES
Acted as
guide to all visitors entering Museum, explalning
Marine Corps bistory, etc _ Also on severel occasions acted a8
5 interpreter for vi siting milftary personnel from Latin America _
10. REASONS For LEAVinG
Dtg cherged
INCLUSIVE DATES (From and To By Mo. ond Yr-) 2.TAME 6F EMPLoying Firm Or AGENCy
July_ 28 1961 August 30, 1961 08 @hto_ValleyEngineering_Company
9 ADoRESS (No. Stroot. City, Stato, Coumtry)
Cepttbl_Gnd I Streets S, W Washington, D C.
KIND Of B UsiNESS NAME Of supervisor
06 06
Construction Mr . L. G _ Bruce
Title f Jod 7. SALARY or EARNINGS 0 . CLASS. GRADE (Ir Fedoral
Servlce)
Laborer 2.17 PER bour
DescRiPTION Of DUTIES
Handynan for Company
10. REASONS For LEAVing
Temporary work while geeking permanent employment
TNCLUSTVE 0A7E577F56m 6nd T6 By Mo: and Yr:) TTAME 6F EMPLOYNG FirM or Agemcy
ADDRESS (No. Stcoot, City, Stato, Cotmty)
KIND OF BUSiNEsS 8 NAME Of supERvIsor
6. Title 0f Job 7. SALARY or EARNINGS CLASS. GRADE (t Fodoral
Sorvlco)
PeR
DescRiption 0f DUT IES
i0. REASONS For LEAVing
0 If Prior SeRVKE With Twe_ FederAL Government 1s NOT Ed Above, Indicate The Hun8hor 63 MRRs credi+;BLe'#8 KRS U.4 civt seRvice REtIRErEnt Tf Kmowm: 7 1/2 years
HaVE You Ever BEEN VischaRGED Or ASkEO To ResigN From AnY Position_ Oyes No
HAVE You Left Position UndER CiRcuMSTANCES Which You DESiRE To EXPLAINP Jyes
Cwo
IF Your ANSMER To Either Or Both QUESTiONs Is "YES" Give DETAILS
Honorably discharged from United states Marine Corps .
5s
3In
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Page 11
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14-00000
SECTION X MILITARY Ser VIce
CURREnT DrAFT STATUS
Are You Registered For The DrafT Under YES 2. selEcTive Service CLassift J. SElective service No. ThE UniveRSAL Military training And cation service ^CT Of 1948 (4o amandod No IV-A 41-65-35-187 35
OefErREd, Give REASON 5 LOCAL DraFT BOARD No. Oa DESTGNATiON And Address
NA #65 101 12 ES San Antonio St,
2oS
2. MILITARY ServIce RECORD LQ (Lockhart Texas
currenT Andtor PAST ORGANIZATIONAL Membershif
CHECK (X) As MARINE AIR coaST MerchaN NATIOMAYAiR NAT'L Foreign ORGAN or Mil: Appropriate Army NAvY CoRPs ForcE Guard MARINE guard guaRD SErVice (Spoclty):
HAVE SERVED~
Now SERVInG None
2. BRANCH Corps Of AbovE ChecKEd organizationis)
Personnel Administration_
DaTE SEPARATED From EXTENDED ACTIVE Duty (Paet aorvicd) IOTAL Lengtm Of Extended AcTive Duty IN U,S. Armed Forces Poai Md cutent [87v105) 25July 1961 Years_
Date Entered PAST service CURRENT service 6. TOTAL LENGTH 0f Active Duty in Foreign Military or Active duty GAniZATiON 26_July,l951
RaNK GraDe or Past service currENt service 0. SERvice, Serial Or File number (IL now borvtne; pPovtdo cu RaTE rent numbar) Cpl (E-4)
PRiMARY MilitaRy Occupation past SErvice currEnt SErvice Specialty (Moo 0 Doclenator) ANDTinue
0141 Chief Clerk
I0. SECONDARY Mil. OccupaTional Past Service CuRRENT service specialty (Mob Or Dobienalot) AND
Title None
Brief Description Of Military Duties (Indlcato whother eppllcable to poet of curtont ,orvico)
Past Service : Clerk MaIntained personnel service records
2 yeer8 a8 Security Guard in the American Embassies in
La Paz , Bolivfa and Lima, Peru,
12. chECK (X) TypE 0f SePARATiom From Active Duty
HONORABLE DischaRGE RETiREMENT For service UNOUE Hardships
RELeASE To inactive Dut Y RetIrEMENT For COMBAT DisABiLiTY Other:
RETirEMENT For Age RETIREMENT For PHYSicAL DisaBility
13. cheCK (X) Component in Which You SERVED
REGULAR RESERVE (Includtne tho National nd Alr Netional Guard) OTheR (Includine AUS)
J. MilitaRy Reserve, NATIONAL GuARD AND Rotc StATUS
Do You Now HAVE X YES 2. Are You Now 4 MemBer 0fT He YES 3. Are You Nom MemBer 0f YES ReservE STATUST Nat L:Grd: Or Aia NATIL. The Rotci No Grd: X No X
If You HAVE ANswered "Yes" To items 1, 2 Or 3 ABOVE, CHECK COMPONENT Membership BELOw
Krmy X MaRinE corps NATIONA L guard COASTGuARD NAVY rotc INDICATE Rotc catEgory Num
ber NAV Air Force Air Nat'lguard ARmy Rotc Air ForcE Rot
CurrEMt RaNK, GRADE Or 6. Date Of AppointmENT im current 7. Expiration DATE Of Current Reserve OBLIgA-
rate Cpl (E-k RaNK Mey 1959 Tion Jenuery 20,1962
0 ChECK (X) Current REserve CATegory REAdY reservE STANDEY( Aculvex X_ STA NOBY(Inactlvo) REtired
Primary MiLiTARY OCcupATiONal specialty (Mob Or Doele- i0. SECONDARY Military OCcupATiOnAL specialty (o' ot Doo_ nator) AnD Title Ienalor) AnD TKTLe 0141 None
1.8rief Description of MilitARY ReservE Duties
None
12. Are You CurrENTLY Assigned Or ATTACHED YES 13. If YOu HAVE AnsweREd YeS" To iTEM 12, Give unit OR AgencY To Reserve, nat'l: guard Or Rotc Train: AND AdDRESS ing umit No
Have You Military Mobilizatiom Assign- YES 15. IF You HAVE Answered "Yes" TD Item 14, give unit Or AgeNCY
MenT And Address X No
16. indicate TotaL Nilitary service YearS Months 17. where Are Your SeRViCE Records Keptt
'or Longevity Purposes incLuD
ing active AND inactiv duty Headquarters Martne Weshington
56 D.c
sin
OR
AL
No
Corps
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Page 12
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14-00000
SECtion Xi: FINANCIAL STATUS
1,ARE You EntireLy dZpEndeNT ON Your SALARY? YES No
2 If Your Answer is ~No' To ThE Above, STATE SoURCES OF OThER iNCOME
Wife 's income
3 BANKing institutions with which YOu HAVE AccounTS
NAME JF institution ADDRESS (City, State, Country)
330 S,w, Bth Avenue
The Bank of California, N.A. Portland, Oregon
15 and H Streets , N.w:,
UnLon Trugt Compeny Waghington,_ D.C
HAVE Ybu EVER BEEn in, Or Petitioned For_ BANKRUPTCY, YeS No
5 . IF Your AnSwER I5 "YES" To The ABOVE, Give PARTICULARS, incLuDinG court AND DATE(S)
6. GIve Three credit RefeRENCES in ThE united STATES
naME ADDrESS (Noo Stroot, City, State)
1310 S.W Yemhlll Street ,
General Motors Acceptance_Corp Portlana Oregon
P.0 Box
521g;
Gulf 011 Corporation Atlanta 9, Georgte
917 Caroline Steet
NInde Furntture Company FredericksburgYirginte
7. Do You Receive An Amnuity From THE United STATES Or district Of ColumBia GOVERNMENT undeR AnY Retirement
AcT, PEnsion, OR COMPENSATion For MilitARY Or NAVAL service? YeS No
0 _ IF Your ANswer iS 'Yes" To ThE ABOvE Question; give ComplETE DETAILS
9_ Do You HAVE Any FinANciAL inteaest IN or OfFiciAL Connections With Non-u.S. CorporAtioNs BUSiNESSES; Or IN
Or with U.S. Corporations Or businesses HAVinG SuBSTANTIAL Foreign interestst
YeS No (Il M0w0t 'YES} fumteh dotailo 0 Joparato eheat:)
SECTION Xii MARITAL STATUS
present STATUS (Sinelo, Merried Widowod, Soperatod, Dlvorced; or Annullod) specify: Married
2. STATE DATE, PLACE, AND REASON For ALL SEpARAtions, divorces OR AnnuLmENTS
NA
WIFE, HUSBAND If have been married more than once including ennulments use separate sheet for former wife Or
OR FIANCE: husbend giving deta required below for 9ll previous marriages If marriage contemplated, {ill in eppropriate
information for (ience.
3_ NAME (Firet) (Mlddlo) (Malden) (Loat)
Dorothy Anne
06 Arnett Flores
State AN Tther NAMES EVER USED indicate CiRcUMSTANCES (Includbe Ianeth 0l tImto) UNDER Which AnY
Of THESE NAMES WerE Used. If LEGAL CHANGE Give PARTicuLARS 0 6
(Whero and by whot euthorlty): USE EXTRA SpAcE provided ON PAGE 16
Doro A Moran of This Form To Record This inpormaTion:
5.DAT E of MARRIAGE PLACE OF MARRIAGE (city, State, Country)
November 14+x1960] Gima Peru Jp
7 his (Or Her) AddrESS Before MARRIAGE (No.= Stroet, City. Stale, Country)
American Embassy__ La Paz Bolivie (o
8. Living 9. DATE Of DEATH 10. CAUSE Of DEATH
X Yes No
currenT ADDRESS (Givo laat Oddro0s , Il docaaood) 06
(2828 Connecticut Ave_ KWx#203 Washington 8 D.C
'2. DATE Of Birth 19. PLACE Of Birth (City, State, Couniry) 14, citizemship
January_ 31, 1935 Portland, Oregon jUnited States of An.
SECTION XII CONTINUED TO PAGE 10
5
5ipi
oR
you
tby
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Page 13
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14-00000
10
SECTION XII CONTINUED FROM PAGE 9
F BorN OutSidE V.S. DATE Of Entry T. PLACE Of Entry
NA NA
16 . Former citizenshipis) [Countryt Iooy 17. 22851886 " U,5. citizenship 70. WheRe Acquired (Cily, Slato , Couniry)
NA NA NA
19_ occupation z0 . PREsEnT EmpLoYEr (Aibo 8lvo (orer employer, or il opouie doceabed O1
tmomployed 8ivo 108t (Wo &mpioyetb)
Le= Secretery Boykin and De
grancis)& 0
Former: Department 0f State
ETPLO ER'S OR business ADDRESS (No., Streot, Stato, Country)
06 1000_16th StusNWS Suite 603 Washington 6, DC
22. DATES Of MilitaBY Service (From and to By Mo. &nd Yr.)
None
23. BRANCH f SERViCE 24_ country with Wrich MiliTARY service AFFILiATED
25. DETAILS Of OTHER GOVERNMENT service, u.s. Or Foreign Foreign Service Jan. 1958 Oct_
1960; Civll Service Aprtl 1961 June_1961_
SeCTiON Xii CHILDREN AND Otker DEPENDENTS
Provide The Following inFormaTion For ALL Children AnD DEPENDENTS
Name RelAtionship DATE AND PLAcE Of Birth citizenship ADdress
None
number OF Other Dependents (tnet--te "podo, #YeE8 %5 SouLoret retudta
Who
Are parento oteppatenta, Mot0r, Otc:) Who Ppont 8
unmarried; under 21 Yrs: Of Age, 28469EM18v4 Vnzf %Q3. 8F i8R
Who
78R887o9
Are amd Not SeLF-supporting. SELF-supporting.
SECTION XiV FATHER (Give sme intomation, br Stepfather and/ o Guardian on 8 separate sheet)
(Laet-Plrot-Middlo) 2. Living 3. DatE Of DEATH CAUSE 0f DEATH
FulL NAME
YES No Gose_ S Flores X
NAMES ME HAS used INDICATE CiRCUMSTANCES (Includbe Ioneth 0t {tmo) UNDER Which He HAS StATs6ther
Ever USED These NAMES: Ip LEGAL ChanGE, Give ParticulaRS (whoro
and by whet authorIty): UsE Extra SPAcE Provided On pAGE 16 Of This
Form To Record This informATion: None
currENT Address Givo Iabt addrou8, Il docoabod (No-, Stroot, Clty, Stato, Coutry)
5
(501 S Guadalupe_ Street 'San_Marcoe Texas
~datE Of Birth 0. PLACE Of Birth (Ciy: Stato, Comtry) citizenship
December20 , 1898 Mier Noriege_ Nueyo Leon_ Mexco_ DSA
10. IF BorN outside U.s. DATE Of Entry M1. PLACE Of Entry
May_2k,_1918
19_ DATE U.5. citize
Tnggom
Where Acquired (City, Stte, Country)
62. FORMER Citizenshipis) [Country(100]
acquired
Mexicen 1957 Austln Texas
16. PrESENT EmplOYeR (Givo [08t omployor, I[ Fathor Io docoaeod 01 memployod)
occupation
Beptigt Minister Mexican Beptist Church
Employer'; Business Address Or 'S business Address if SELf-employed 74783r"
Goz S Guadelupe_ Street San_Marcos Texas
Dates 0 service (From-and-To} 19. BRANCH Op service 20_ countRy Y8
my
'Triownea
never
#8334047 8P6+ ovi8i aovt Enf JenVee,se8r
#oreigN
5 %
ga1
Clty:
age
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Page 14
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14-00000
SECTION Xv MOTHER ve same inlormation Jor Stepmolher on 8epa ra te sheet)
FuLL NaME (Last-Piti-Midulo) 2 ning 0, DATE 0p DEATH cause Of DEATH
flores,(Agustina ob Y2S Xhne June 1939 Unlnow
State Other NAMES ShE HAs Used INDTCATEVIRCBMSTANCES (Ineludba loneth 07 76m6) UNDER Which ShE HAS
Eve UsECAThESE NAMES. if LegAL chANGE, Give PARTicuLaRS (Whoro
what 00 aorlty). use Extra SPAcE Provided ON Page 16 Of this
None to mY
Iovledge Form To RFcorr This INFORMATion.
curRENT AddResS Give Last Adoress, IF DECEASED (No., Streot, Ciy Stato, Country)
S Austin end Lee Streets_ Marcos Texas
GatE Of Birth 8. PlacE Of Birth (City; Stto, Country) ENSATA
September 20, 1903 Mler Y Norfege , Nuevo Leon, Mexico Mexlcan
10. IF Born Outside U.s_- DATE OF EnTry PLAcE Of ENtry
Unkow Unknown
2 Former citizenshipis) [Cantrytlooy 13, DATE U.s. citizENship 14. WherE Acquired (City, Stto, Cotutter)
AcquirEd NA NA NA
OCCUPATiON 16. PRESENT EMPLoYER (Give Iaet employor, 1 Mothor I0 docoabod 0t Lmtomployod)
Hougewife NA
EmpLoyer'S Business Address OR Mother's business Address iF SELF EMPLOYED
NA
3 DATES Op Military SERVIcE (From-and-To) 19. BRANCH Of service 20. COUNTRY
NA NA NA
21= Details Op Other GOV ERNMENT serVice, U.s. Or ForEigN
NA
SECTION Xvi BrotheRS AND SISTERS (Including Half-, Step- and Adopted Brothers and Sisters)
FULL NAME (LablPlrt-Mlddlo) 2 RelaTionship citizenship (Country)
Petlan,Frances >b Sieter 0.8. of America
CurrenT Address (Noss Clty, %ono, Sete, Colmtry) 3. Living 6. Age
631 8 River sto
56o3
2
Seguin Texes Yes No 41
FuLL NAME (LabfFborMIddlo) 2 ReLationship 3 Citizenship (Cotntry)
(Renteria Racbellob Sister 0,S. of America
2
Current address (Noi sopot; Clty, zono, State: Coumtry) 9. Living 6. AGE
(311 Lamert St.fv San Antonio Texas YES No 39
~FULL NAME (LabrFbot-{lddlo) 2. ReLationship 3, Citizenship (Cotty)
Black Rebecca 6 Sister U.S _ of America
Current AddreSS (No' Stoo6, CltysZono, Stato, Contry) 5. Living 16. AGE
501 8 Guadalupe St9b San Marcos Texag X Yes No 34
FuL NAME (LabrFbar-MIddo 2. ReLATionship Citizenship (Camtry)
Flores (Samuel 06 Brother U.8, of Americe
CuRREnT Address 5rog {regt93 Steto, Coantr 5. Living 6. AgE
Rogemary ana Seguln Texag I YES No 32
FULL NARE (Laot-F7rot Wddlo) 2. RelATionship citizenship (Conlt)
eb Brother U_S of America UAEAs1c;
Curremt To , Suo0t, Clty, 8onos Se3t0, Corntry) 9 Living 6. AGE
Route 2 Box 320 San
Negeo8 Texas X Yes No 29
FULL (LaetFiret-Middlo) 2. Relatiomship Citizemship (Contry) Mog
Bruce Egther Sister 0,S of America
currEnT Address (Noj, Clty, Zono, Stato, Country) 5, Living 6. Age
7252 Exmore_ st
85SprinEf;813) VirEinla_
X YES No 27
TuLL NAME (La8r-Fbot-Middlo) 2. relationship J Citizenship (Comtry)
Flores_ Eleazar)ob Brother U.S of America
current AddResS (No, Stroot, Clty; Zono, Stalo, Country) 3. Living 6_ AGE
Deceased YeS NO 7
pulL NAME (Labl-Fbor Wddlo) 2. Relationship citizenship (Collty)
Flores GJuenJeb Brother 0.S_ of Amer Ica
Curremt Address (No} Stroot, Clty: Zono, Stato, Contry) 8, Living 6. AgE
Deceased Yes X No NA
11
39
(frv
ui-
and
obsen
MarzJg
8Gheputa
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Page 15
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SEctiON Xvn FATheR-In-LAw
NAME (Laet-Firet-Middlo) 2_ Living 0. DATE 0f DEATh CAUSE of DEATh FuLL
Arne Carl
Rerond 06
YES No
5 STAtE Other NAMES HE HAS USED INDicATE CiRcuMSTANCES (Includie Iongth 0t time) UNdER which He HAS
EvER UsEd these NAmES: If LEGAL CHANGE, Give PARTicuLaRs (Wero
and by whet authority)- USE EXTRA SPACE Provided ON PAGE 16 0f this
Form To Record This infORmATion: Ray
cuRrEnT Or LAST Address (No-, Stroel, City, State, Country) 0
4505 WashIngton 8t0 MIlweukle 22 Oregon __
DATE 0f Birth 0. PLAcE Of Birth (City, State, Country) citizenship
January 2, 1909 MInot North Dakota 0.8, Of nmerice
10. If BorN OUTSiDE U.S. DATE Of Entry PLAcE 0f Entry
NA NA
[Country{ Ieey 13. DATE U.S. citizenship Where Acquired (City, Stato, Cotntry)
12_ Formea citizenshipis)
NA Acquired NA NA
16. PrESEnT EMPLOYER (Give larl employor, Il Fathar-i-Law i0 doceaeod Of U omployod)
15 _ OCcUPATION
Werebouee Poreman Gudy WIlbelm Ino Portland Oregon
SEcTION XVI Mother-IN-LAW
NAME (Labt-Fltst-Midulo) 2. Living 9, DATE Of DEATH CAUSE Of DEATA FULL
Tompktng Alma Dan)oG YeS No
STATE Other NAMES She HAS USED indicate CiRcuMSTANCES (Ineludine Ieneth 0l tmo) UNDER Which she HAS
Ever USED These NAMES: IF LEGAL CHANGE, give PArticuLars 'Wnoro
mnd by shat authority} Use EXTRA SPAcE Provided ON PAgE 16 OF this
Ala Dean
AGnett_
Form To Record This iNFORMATiOn:
cuRREnT Or LAst AdDress (No-, Stroot, City, Stato, Country) 0o
13920 8,B, Portland VJon Place
Portl and_36) Oregen
DATE Of Birth 6 PLACE Of Birth (City; State, Colntoy) itizenship
Mey 4 1910 Portland Qregon 0,8, 0f AmerLc
10. If BORN OUTSidE U.s. DATE Of Entry 11 PLACE Of ENTY
NA NA
1J. DATe U.s. citizenship Vmere Acquired (City: Stato, Country)
12. forner citizenshipis) [Cotrx{loby
NA Acquired NA NA
6. PRESENT EMpLoyER (Givo /a8t omplojor; M Motherm-LBw 10 deceaded or uomployod)
15. OccupATion
Homemaker
RELATNES By BLOOD MARRIAGE Or ADoPTION WhO Ether (W Live ABROAD_
SECTIOn Xix 7(2) ARE Not U.5. CiTIZENS OR (J) VoRK FOR ForeIGN Gov ERNMENT
2. RelAtionship 3. Age
FULL NAME (Labt-Flret-Middle)
None to m
knowledge
AddresS OR country IN Which RELATive Resides 5. EMpLOYED BY
2
(Colntry) FrequenCy 0f CONTACT 0. DATE Of LaST ContaCT 6. citizenship
2 RELATionsmip 3_ AGE
Fuli NAME ( 'Last-First-lddle)
Aodress OR country IN which RELATive Resides EmpLOYED By
(Country) 7_ frequency Of CONTACT 0. DaTE 0f LAST CONTACT
6_ Citizenship
(Laet-First-Middle) 2 ReLationship 3 Age
UL NAmE
Adoress OR Countay in which ~ELATIVE REsIOES 5 Employed By
citizenship (couniry) 7 Frequency Of CONTACT DATE Of LasT CONTACT
FULL NAME (Labi-Firs{MMiddle) RELATionship 3 AGE
Address or country im Which Relative RESidEs 5. EmPLOYEd 0y
citizenship (colmin) Frequency Of contACT 0. date Of LasT contACT
SECTION XE CONTINUED TO PAGE 43
k0
Gl
tte
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Page 16
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14-00000
SECTION XIX CONTINUFD FROM PAGE 12
SPECiaL REmARKS, if Any, concerning RELATives NotEd im Sectiom Xix ABove
NA
SECTION XX RELATIVES BY BLOOD, MARRIAGE OR ADOPTION Mio ARE IN ThE MILITARY Or CIVL
SERMCE Of The UNITED STATES
NAE (Leot-Flret-Middlo) reLationskip Age Citizenship
Arnett, Raymond_Wesley 86 Bro-in-law 24 LS, of America
ADDRESS (Noj, Streot, City; Stato, Cointry) Type and Location oF SERVicE (Il Knorw)
U.S_ Army_Depot Pueblo, Colorado
NAME (Laat-Ptrat-Middlo) RELATionship 3. AGE citizenship
Mller, Claude 06 Znd Cous in Unk U,S Of America
5 AdDR ESS (Novi Sub84 City; Stato, Corntry) 5 Type and Locatiom Of ServicE (1i Kowr)
Air Stetton,_ Quantlco Virginie_ Avlation lat Sgt USMC
nnE (Laat-Firet-Ulddle) 2. ReLATionship 3 AGE citizenship
Address (Noj, Stools State, Camtry) TYPE And Location Of service (Il Kor)
SECTION Xxi REFERENCES, ACQUAINTANCES, ANd Neighbors
I.List Five ChARACTER REFERENCES, Not RELATIVES, in ThE U.S-, Who KNOw You InTiMATELY
NAME BusinesS Address RESIDENCE ADORESS
(Laat-Firet-Middle) (No. Stroet, Cily and State) (No:, Stroot, City end Stte)
S_ Guadalupe St.>
Mr and Mrg (Joge
Eep?hol
a San Marcos Texes (San _Marcos Texes
Car26e Flrst Baptist Charch)
Rev Pearedes Austin Texas Austin, Texes
0430 Eg St., 3742 Jeson Avenue Jo6
Mr (harter L
Gecd81
Weghingtn DC Alexandrta Virginfe
1711 Magsechutes Ave
Jo5
Mr G1fred
Bedbx'
Dept_ of Agriculture WeshIngton= DC
06 Tbe American Embassy, 172 Bartolome
HerrerdDo{ ,
Cpl Michael Hennessy Lima Peru -Miraflores Lina Pex
2. List Five PERSOmS; in TkE U.s. #ho Khow YoU SOCIALLY not RELATiVES, Supervisors Or Employers
NAME BuSinEsS AodrESS RESidENCE ADdrESS
Laet-Flcat-Middlo) (No., Steoet, Clty and Stote) (No., Stroot, City and Stato)
Department of State , Hill House
Mr Howard Jr Washington 25, DC EuclidStsy_Wasb
he 18571 Section Road,)8
Mr_(Max_ Klncinnatt36._Qhiq
o6 Department of State, Illen Lee Hotel_ 23rd
MJss Mary_Ann_Newman Washington 25, DG 2 8t8 , _NMy_Wash
06 ko1 Cascade )o6
MLgs Ruth_ F Stenart Boulder,_Colorado
06 p73 Bartolome Herrere} 6
Mrs @ea_Luzl_
Miraflores,_Lima, Per
1. List ThREE Neighbors At Your Most RECERT NORMAL ReSideMce in The U.S.
NAME Business AddresS ResidENCE ADoRESS
(Laat-Flre t-Middlo) (No._ Stroot, City ond Stato) (No.= Stroat , and Stato)
Mia8 (ancy Payne_ 06 402 Hanover St.
Brederlckaburg _Virginlia
Lt. and 1/ Lee Pelts 06
Mrs_ (W1ll1en
Eau?qan)
Boute_L_Kennetty
Mo
13
Cim'
T.w)06
top
Nickland
ciy
&ht
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Page 17
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14-00000
SECTIOn Xxii CLubs, SoCieTIes, AND Other ORGANIZATIONS
NOTE: List names and addresse8 of all clubs, societies, professional gocieties _ employee groups Or organizations of any kind
(Include membership in, or 8upport of, any or8anization having headquarters or branch in 0 [oreign country) to which you
belong or have belonged
DateS Membership DDRESS NAME And CMAPTer (Nenber,Gtfeot, City, State, Country) From To
San Marcos High School,
SpanLsh_Club_ (0 (an_Marcos Texas_ Sept4l95] 1955
7en Marco s High School, Sept_ 1925
Distrlbutive_Education Club San_Marcos)@ Tezes 1954
Rirst Mexican
Bapt1s0C jggz
Baptist_Youth_Organization Church [Gan_larcog_Tex - 1957
j0
SECTION Xxiii RESIDENCeS For ThE PAsT 1} YEARS
incLUSiVE DATES ADDRESS LaST RESidENce First
(Nurnber, Staot, City; Stato, Country) From To
6 4736_Kenuore_Avea , #201) Alexendrla Virginta Merch _1961/Aug 1941
06
4Q2 Hanqver_Sta) Frederickaburgs_Virginla Dec .,1960 [Mars, 1941
05
672 Bartolome Harrera,_Miraflores Lima Peru
Jan.1960
Noyc,194o
Calle Potogi,
USIS_Bufldings_3rd &hth Floors La Paz Bolivta NoVxsl958 Jan,,1940
Company , Headquarters Marine @orps
9
Hendergon
Hall Washington 25,_ DC
Sept_l958 _Novzl998
Cold Weather Training Battalion, Pickle Meadows ,
Bridgeport_ Celifornia
Jen , 1958_Aug 1948
Marine Corps Bese 29 Palms Celifomta
Dec '_1951_Jan :1958
Marine Corps Recruit Depot San Diezo_ California July l9S]_Noy 1957
Marine Corps Base Camp Pendleton Cal ifornie Noy sl953 Dec_b 1957
501 S _ Guadelupe St_ San Marcos Texes May_1956 July 1957
Howard Paxe_College Brownwood Texas Sept_195_Meys1956
501 S_ Guadalupe Sta Sen Mercog Texas 1946 Sept~1l955
(pf
0f
May
May_
Tp
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Page 18
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14-00000
SecTION Xxiv ADDITIONAL INFORMATion
You or HAVE You Ever ADVOCATED; Or ARE You now or HAVE You Ever BEEN A MemBER Of; YES 88
HAVE
B88e NB Ever supported Or BeEN Associated With ANY POLiTicaL PaRTy inDividUAl Or ORGAN
izATion Which ADVOCATES Or TeACHES The Overthrow of ThE GovernmenT Of ThE united STATEs BY
ForcE VIoLERCE Other UncOnsTitutiOnAL MEANS OR SEEKS By FORCE Or Violence To DENy Persons
Their Rights
3SB8R
TKE Constitutiom Of The united STATEST X no
2 IF You KAVE ANsweRED "Yes" To ThE Above Question; ExPLAin
YES If S0, To WMAT EXTEnTT
3_ DO You UsE Or HAVE You
EVER used intoxicantst X 4o
6 If SO, To WHAT ExtenT?
53 Do You Use Or HAVE You YEs
EVER USED NARCotICST I No
HAVE You EvER BeEn A MeBER Of , Or supported, Or HAD ANy ConnECTions With A Foreign intelligence ORGAN-
iZAtion or its Activities?
YES No IF AnsweR I5 'Yes" Give COMPLETE DETAILS.
0. List Below The NAmES Of GovERNNENT DEPAFMEMTS, Agencies Or offices To Which You HAVE Appliedtfor EM
PLOYMENT Since 1940
I served 4 years in tbe Unlted States Marine Corps _
If To Your KNOwLEDGE Any OF The ABOVE HAVE CONDUCTED An INVESTigATion Of You, indicate The NAME Of Tke
AgEnCY Amg #he Approximate DAFE %F THE iNVESTigATion:
An Investigation I do not know by whom) wes conducted prior
to my departure for Bolivla where I was attachbed to the American
Embas This investigation took place during August and: September
of
1958;
NOTE SPECiAL If yout onsrvror Is "YES' to the tollowing Questiont 10, Il e 42, Povido the Informotion requosted for och
INSTRUCTIONS quottion 6n 0 goparate, slgned shoet and attoeh tho shoot to thl: form In soaled envelope.
10. HavE Or To KNOMLEDGE HAS Your spouse, Ever Been DET AINED_ Arrester' inpicted Or_Com
Victed
88x8r8
Amy
vi8u3+t89
OfThe Latother THAN A' MuNORTrAFFIC Violation iN The umiteo States Or YeS
Abroadt
F So_ STATE NAME Of court city, stAte_ country_ DATE, NATuRE Of OFfENsE AND Disposition 0f caSE
in ACCORDANCE Witm ThE SpeciaL instruction ABOVE. X N6
MAVE You EveR Been court-MARTIALED Qr Otherwise PuNisHER UNder WiLITARY LAC Qr REG-
ULATiont TF So. Describe
Ri8eEGBES9UR
ANd provide DAteis) 0f OccurrencE ON SEPARATe SHEET Im Ac
CorbaNCE with specint instructions Above_ N Xi
12 ARe There AnY UNEAVORADLE UNCIQENTS JN Your L4fe:NQt MENTIQWEr ^bove Which MAy BE Discovered
i subseQuENt IMVESTIGATIOM= You wEre Directl INVOlVED Wmich Might Require Ex:
PLanATiom if S0, Describe
1eietites And Provide Dateis) Of OCCuRRENCE ON SepaRATE sheet iN AC
CGRDANCE With SPECIAL instructions Above. No
SECTIon XXV PERSON To BE NOTIFied IN CASe OF EMErGENCY
NAME (Firat-Mlddlo-Last) RELaTionship
Mrs Daniel Flores_ Wife
3. HomE ADDRESS (No-, Street Cily: Zone, State_ Country) Home PhomE No.
2828 Conn
Avede #203.) Washington 8,_DC, 2265_8322
DUS NESS ADDRESS (NNo:. Su6o0, C1t7,, Zono, Sito, Colmtoy) inDicate NamE Of Fian Or 6. Tusiness PHONe No. ExT.
EmpLo er, if APPLicABLE
Boykin and De Francis 08
1000 16th St., Suite 603 Washington 6, DI 7-5444)
in CASE 0f OTteR CLOsE RELATIVES (Spoune Mothor, Pother) MAY ALSO Be Notified: if Such notification
Is Not Desirable;
RBEeT8Exu88
Of HeALTH OrOtheR REASONS, PLEAsE So state: 26
In all ca808 wife : Relative Mrs Nicente Patlan) 631 S . River
StJ o
(0
(Seguin) Texas Telephone Gr 9-1087J35
15
Strv
Nox or
D.C .
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Page 19
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14-00000
SeCTioN Xxvi CERTiFicATion
You ARE INFORMED THAT THE CORRECTNESS OF ANY STATEMENT MADE IN This APPLICATiON
WILL BE INVESTIGATED.
have read and understand tho Instructions. Cenify thot tha foregoing answers Ore trya and corect to the best of
knowledge and belief. ogrec that &ny misstatement 0r omission 0s to moterial fact will constitute grounds tor
tronedote
dismissol %r rojectlon 10f applicotien: als understond that any folse statement madk herein moy bo punishoble by
low (U.S: Code, Tltle 18,
recponicdon"
DAS E 0f 2 SiGn URe Of AppycnnF TTunL A
LSLL
ZbL
si9Ed At (Clty end Stoto) Of witness
Wagbington Dstrict of Colunbia
TzE6L
NOTE: Uee the following space {or extra deteils. Relerence each continued item by item number t0 which it relates,
Bign you neme at the end of the added materiel_ If additional space i8 required
Irectiorend
extra peges the Bame size 08 this
page and sign each such page-
MARITAL STATUS : Item #4, Section XII
September 1956 to October 6, 1956 Married to Lt. Col. Joseph G .
Moran) In Portland, Oregon,_ by Circuit Court Used nane of (Moran}
until November 1, 1960 , wben changed to Flores . 06
FATHR-IN-IAW: Item #5, Section XVII
Short name for Reymond
GEOGRAPYIC AREA KNOWLEDGE AND FOREIGN TRA VEL : Iten #1, Section VI
ArgentIna 2 July 1959 to 3 July 1959 - Travel
Paname 10 November 1958 to 13 November 1958 Travel
SEE ATTACHED SHET FOR PERTINENT INFOR MATION RELATIVE TO STEP-MOTHER _
S1gned at Washington, D. this
Tt day
of September,
1961.
~byL2h
DanTel Flores
2/Fv
1,
Judge .
C.,
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Page 20
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14-00000
ATTACHENT To FORM NO , 4444
Fa
PERSONAL HISTORY STATEMNT
Section XV STEPMOTER
06
Full name (Concepcion R Flores
Living: Yes
Other Name $ She Used: None to my knowledge
Current Address : S _ Guadalupe Street, San Texas
Date of Birth: December 8 , 1914 06
Place 0f Birth: Mexico
Citizenship: Mexican
If Born Outs ide U.S_ Date Qf Entry : December 8 , 1922
Place of Entry : Unkown
Former Citizenships : None
Occupation: Home maker and Miss ionary 06
Present Employer: Mexican Baptist Church, SanMarcos Texas
Never gerved in Military or other Governme nt service t0 my bowl
This paper is attachea to &n d he reby made 8 part of Form No 444.
~Zeu
Daniel Flores
3lpd
Bagoi
Marcos)
edge.
65