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19.  ARE THERE INCIDENTS IN YOUR LIFE NOT MENTIONED HEREIN WHICH MAY REFLECT UPON YOUR LOYALTY TO THE UNITED STATES OR UPON YOUR SUITABILITY TO PERFORM THE DUTIES WHICH YOU MAY BE CALLED UPON TO TAKE OR WHICH MIGHT REQUIRE FURTHER EXPLANATION?  [] YES  [X] NO  IF "YES," GIVE DETAILS

20.  REMARKS


I CERTIFY THAT THE ENTRIES MADE BY ME ABOVE ARE TRUE, COMPLETE, AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF, AND ARE MADE IN GOOD FAITH.  I UNDERSTAND THAT A KNOWING AND WILLFUL FALSE STATEMENT ON THIS FORM CAN BE PUNISHED BY FINE, OR IMPRISONMENT OR BOTH  (See U.S. Code, title 18, section 1001)

DATE  ^[[1 Sep '64]]
SIGNATURE OF PERSON COMPLETING FORM  ^[[B. O. Davis, Jr.]]
TYPED NAME AND ADDRESS OF WITNESS  ^[[ALICE M. YODER, Hq USAF, AFOMO]]
SIGNATURE OF WITNESS  ^[[Alice M. Yoder]]

21.  THIS SECTION TO BE COMPLETED BY AUTHORITY REQUESTING INVESTIGATION
BRIEF DESCRIPTION OF DUTY ASSIGNMENT AND DEGREE OF CLASSIFIED MATTER (top secret, secret, etc.) TO WHICH APPLICANT WILL REQUIRE ACCESS

RECORD PRIOR CLEARANCES
DATE OF CLEARANCE | TYPE OF CLEARANCE | AGENCY THAT COMPLETED INVESTIGATION

REMARKS


U. S. GOVERNMENT PRINTING OFFICE: 1964 O - 743-473
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