Alien Accounts (16 page)

That about concludes my remarks, except for one. Diet and beatings have greatly altered my appearance. Loss of weight has wrinkled me, I’m missing most of my hair and teeth, my nose is broken, etc. Now, even if Agent Barkley were to stride in here in his well-padded suit and look things over, I doubt very much if he could recognize me as one of the ‘wanted’.

NOTE: The above MS is attached to form MP-788 1-b, apparently filed at the Bureau of Missing Persons on the date shown. It was found crumpled down in the back of the file drawer. Not signed. Disposition: Destroy.

(Approved) Lazarus Cameforth

Bureau Chief

Directions.

READ CAREFULLY. Before answering any of the questions below, be sure to have all pages of this form, in order. Fill out in triplicate, using ballpoint pen or, preferably, indelible pencil. Press hard. PLEASE PRINT. Sign name to all copies.

1.
  State full name at present: ____________________

2.
  Full name at birth, or baptism: _________________

3.
  Give
any
aliases, abbreviations,
or nicknames
by which you have ever been known: ___________________

4.
  Attach copies of birth and baptismal certificates.

5.
  Social security number: _________________

6.
  Name on your last income tax return: ____________

7.
  Date: __________
8.
Date of tax return: ____________

9.
  State your full permanent address: __________________
___________________________________________

10.
Where may you be quickly reached by: a)Mail: ______________

b)Telephone: ___________________

c)Telegram or cable: ___________ d)Messenger: ___________

11.
List every address at which you have resided, since birth, in chronological order. Include
every
address, with the following exceptions: a) Hotel accommodations in the United States, Mexico or Canada, for stays of up to or less than three days, occurring more than five years ago. b) Accommodations at U.S. Embassies, in other than an official capacity, for any duration, occurring more than seventeen years ago. c) Antarctic expeditions not using APO addresses. ALL OTHER ADDRESSES MUST BE SHOWN, WITHOUT EXCEPTION. Note: extra sheets (Form AR-B Supplem) may be attached.

Street address:   City:   State:   Date from: Date to:

12.
Occupation: _________________________

13.
Name and address of company where you are presently employed/were last employed: ____________________________________

13a
Last position held:

14.
Salary: ____________
15.
Name of superior: ______________

16.
Starting date: ____________
17.
Terminating date: __________

18.
Attach references.
19.
If unemployed, give reason: __________

20.
Why did you leave your last job? __________________

21.
Give your entire employment history, except for your last or present job. List all employment in chronological order, and include part-time employment. Note: Extra sheets (Form AR-B Supplem.) may be attached.

Company name and address:

Position

Supervisor

Salary

From

To

Reason for leaving

22.
Have you ever been fired for: a)Theft: ______ b)Embezzlement: _____ c)Dishonesty: _____ d)False References: _____ e)Absenteeism: _____ f)Tardiness: _____ g)Loafing: _____ h)Inefficiency: _____ i)Personal reasons (Explain): __________________________

23.
Have you ever quarrelled with fellow employees? ___________

24.
Have you ever had difficulty with employers? Describe: ______________________________

25.
Have you ever stolen any property belonging to an employer, no matter how small in value?
26.
Have you ever feigned illness? _______________________

27.
Name of your bank or banks? _________________

28.
Explain any foreign bank accounts: _________________

29.
Bank Account Number(s): _____________________

30.
Present balance(s): ________________________

31.
Number and amount of withdrawals during past year: ______________________________________

32.
Father’s name: ______________________

33.
Mother’s maiden name: _________________________

34.
Attach birth certificate and marriage licence.

35.
Have you ever been arrested a)As a minor: _____ b)As an adult: _____ c)Misdemeanor? _____ d)Felony? _____ e) Convicted? _____ f)Sentenced? _____

36.
Give full details of any arrest and/or conviction, including name of offence, whether convicted, sentence and/or fine. Include all traffic offences other than overtime parking.

37.
Do you love your mother more than your father? __________

38.
If you do not love your mother, explain: _____________

39.
Circle which of the following you have ever suffered from: a)Rheumatism b)Arthritis c)Chronic fatigue d)Rupture e)Tuberculosis f)Night sweats g)Nocturnal emissions h)Nightmares (frequent) i)Sleepwalking j)Ringing noises k)Chronic or severe headaches l)Bronchitis m)Homosexual tendencies n)Hot flushes o)Tumours p)Cancer q)Gastric ulcer r)Gonorrhea s)Syphilis t)Asthma u)Hay fever v)Severe cough w)Trenchmouth x)Hepatitis (jaundice) y)Diabetes z)Anaemia aa)Poliomyelitis ab)Heart attack ac)Stroke ad)Heart murmur ae)Blindness af)Deafness ag)Tunnel vision ah)Astigmatism ai)Unexplainable pains (Explain) aj)Visions ak)Epilepsy al)Impotence am)Obesity an)Chronic nausea ao)Drug addiction (Explain) ap)Alcoholism aq)Double vision ar)Frequent or severe accidents as)Amnesia at)Laryngitis au)Malnutrition av)Precognition aw)Cleft palate ax)Harelip
ay)Multiple digits az)Paralysis (specify).

40.
Have you ever had any serious physical or mental disorder? Describe, specifying dates, physician, treatment, hospitalization etc.: _________________

__________________________________________

__________________________________________

41.
Briefly describe your own condition at present: ____________

42.
Are you under medication? Describe: ___________

43.
Attach medical records and physician’s affidavit.

44.
Have you ever undergone surgery? Describe: __________

45.
Have you all your natural teeth? (Attach chart) ______________

46.
Describe any amputations, giving dates and reasons: ______________________________________________

47.
Have you: a) Both kidneys b) Both lungs c) Ovaries d) Prostate e) Gall bladder f) Both eyes g) A bladder h) A complete stomach i) A complete colon j) Both breasts k) Lower jaw l) Nose

48.
Have you ever undergone sterilization? _____________

49.
Castration? ____________
50.
Hysterectomy? ____________

51.
Do you feel sexual desire for, about, during: a) Those of your own sex b) Those of both sexes c) Children d) Your mother e) Your father f) Your son g) Your daughter h) Sister i) Brother j) Babies k) Cadavers l) Animals m) Birds n) Fish o) Insects p) Cripples q) People who hurt you r) People whom you hurt s) People of special professions (describe) t) People in particular costumes (describe) u) Watching others in the act of coition v) Peeping at naked persons w) Drinking blood x) Drinking urine y) Drinking semen z) Eating faeces aa) Looking at photographs ab) Looking at drawings ac) Drawing pictures ad) Telephoning ae) Confessing sins af) Listening to music ag) Dancing ah) Exposing one’s sex organs to someone else ai) Anal entry aj) Axilial entry ak) Oral entry al) Nasal entry am) Rape an) All
members of the opposite sex, regardless of age or condition ao) Watching movies ap) Watching television aq) Performing your ordinary work ar) Masturbating as) Urinating at) Defecating au) Menstruating av) Wearing clothing belonging to the opposite sex aw) A particular part of another’s body ax) Of your body ay) Crowds az) Rubbing against people ba) Clergy bb) Weapons bc) Machines bd) Plants be) Trees bf) Sunsets bg) People of other races bh) Apparel bi) Dangerous or unusual surroundings bj) Inanimate objects bk) Mathematical propositions bl) Thoughts bm) The law bn) God bo) The act of filling out a form

52.
List all the persons in your household:

Person:

Age:

Sex:

Income:

Source:

Relation to you:

53.
Why do you believe you have been asked to fill out this form? _________________________________

54.
Describe briefly your feelings about filling out this form: ______________________________________

55.
Describe in detail other forms you have been asked to fill out, explain their use, and estimate your performance: _____________________
_______________________________________________
_______________________________________________

56.
Describe your character in detail, giving examples of your behaviour to illustrate points. Note: extra sheets (Form AR-B Supplem) may be attached.

____________________________________

____________________________________

____________________________________

57.
Do you believe in God? ______ If ’no’, explain: _____

58.
Have you answered all the above questions? ____________

59.
Have you answered truthfully? ____
60.
Have you ever lied? ____