PERSONAL HISTORY STATEMENT
Date (Official): July 5, 1964
Instructions:
1. Answer all questions completely or check appropriate box. If question is not applicable, write "NA". Write "Do not know" if you do not know the answer and cannot be obtained from personal records. Use blank space at end of form for extra details on any question for which you have insufficient space.
2. Type, print or write carefully; illegible or incomplete forms will not receive consideration.
3. Type, print or write answers carefully. Your signature at the end of this form will certify to their correctness. Careful completion of all applicable questions will permit review of your qualifications to the best advantage.

General Personal and Physical Data:
1. Name: [Redacted]
2. Sex: Male
3. Date of Birth: [Redacted]
4. Place of Birth: [Redacted]
5. Citizenship: [Redacted]
6. Physical Description:
Height: 6'0"
Weight: 180 lbs
Eyes: Blue
Hair: Brown
Complexion: Fair
Build: Heavy
Scars or Marks: Deep scar ("2") on left part of forehead

7. Present Address: [Redacted]
8. Permanent Address: [Redacted]
9. Telephone: [Redacted]
10. Marital Status: [Redacted]
11. Dependents: [Redacted]
12. Other Names Used: None
13. U.S. Military Service: [Redacted]
14. Position Applied For: Russian Language Linguist
15. Salary Desired: $10,000
16. Date Available: 2 weeks after notification
17. Willingness to Travel: Yes
18. Willingness to Accept Assignment: Yes
19. Remarks: Possibility of schooling for children

[Photograph attached at bottom right corner]