CONFIDENTIAL
DOCUMENT IN QUESTION

STATEMENT OF FEDERAL CIVILIAN AND MILITARY SERVICE

PLEASE READ INSTRUCTION SHEET BEFORE PREPARING THIS FORM

Name: [Redacted]
Address: [Redacted]

1. FEDERAL CIVILIAN SERVICE: BEGIN WITH THIS AGENCY AND FOLLOW IN DIRECT CHRONOLOGICAL ORDER.

Name: Central Intelligence Agency
Location: New Orleans, LA
Dates: From 1/1/1947 to 12/31/1954

Total Civilian Service: [Redacted]

2. MILITARY SERVICE (INCLUDE ONLY PERIODS OF ACTIVE DUTY; DO NOT INCLUDE TERMINAL LEAVE).

Branch of Service: U.S. Marine Corps (Reserve)
Dates: From 9/9/1942 to 1/1/1946

Total Military Service: [Redacted]

3. CERTIFICATION

I hereby certify that the above Civilian and Military service is complete and accurate to the best of my knowledge.

Date: 31 Dec 54
Signature of Certifier: [Redacted]

BY REMARKS: (CONTINUING ABOVE SERVICE)

FOR PERSONNEL OFFICE USE ONLY
TOTAL CREDITABLE SERVICE
Days: 33
Months: 5
Years: 7

MAY BE CONTINUED ON NON-DETACHABLE REVERSE SIDE.