FULL NAME: Gen. Rufus H. Lane, Falls Church, Virginia, retired Marine officer; Assistant Jack D. Neal, State Department, Washington (FAC), State officer; Eric E. Tomlinson, State Department, Washington, State officer.

[Various questions and answers are filled in the form, including handwritten notes.]

Date: 3 Oct. 1946

[Signature and official stamps are present at the bottom of the document.]