DS9 Document EFTA01247971

10. 41, . . — — — ord Recast 125 (Rev. 4.1.93) W 11, 111 C1 ILILOPCMIXt4S74Arlit2S1 — — — — — — — — — — — Wr • _ Oate D0/0 ) /Zoo G 0 Birth 0 Credit Criminal • heath 0 INS 0 Karr *pew Motor Vehicle 0 Other To I Ait Buded File mater ste- ',Aril,- 166O62 - /A Return to Ss Name and atlases f subject, epplIcent, or employee, and spouse Addresses Residence/ RP TS WC- Business former *Cate and place o marriage (If ePplic 0 Ran A Male female Age Neight S . W. weight Heir Eyes Birth date Birthplace IS:./.__. Arrest MVater fingerprint classification Criminal specialty Social Security Drivers license Haber 0 0/l. Photo • Other Specific information desired ACC—.1./7-1 11/4)4' Results of check CC-a Is it— er/ 14-orti e LAce-'k CONFIDENTIAL /32- 3501.182-015 Page I of I EFTA_000719 I I EFTA01247971