U.S. DEPARTMENT OF JUSTICE Employee Locator Information
04gTRUL-11046: ytb Si, bb oonstaf by d mina Lyntam(niers:To (Lomt coNnew any Larrnmcnm Cs am mama, Czyrma del 1:0 parp8p40:02:01.1Ramie do
yos prsord cam In oetatortowth protRas d Tv Picu.YM d 1974. a0. Colon d Geo M MANDATORY,mars, b rot On GASSMAN tsta elv cloty QMmooring
or overran The YMCAS:Ma AOLUMARY re10 of re CU Ainciceml to Ye ownS•Pacn Ad Sent Cat' Pr," d tiOrminb t°egnilniby t*niuMnre‘terS amend
ante nom Era= mufti tem Cub yearn d To OnMeet 3 you /merry pastcre rga-Sreconker d Cs am Musa teal pas oceans aft.
EMPLOYEE IDENTIFICATION
PRVACY ACT STAMM: SOCIAL SUMMIT NL2361-1 AUT1=ITY• En:4410 Cot/ ITMS =41tOrenter 22, 1041 2 PL10414r An use ma sadorso2s2y Know:TOMum:1m am*,
Kura tx ratetteg kalercometo to tat: pared umpun: area Lao at Co ESN aurae mitt ,0024::40 of fixate ewe-Moyom nth:0 lane in 1 EFFECTS OF NOP 00011‘4124
72.
cid* 11:41b MANDATORY. Fetszo 0 Sid= Co SM4 en =Sal retl oats 0 yamLy resol art COM crocomod Fire 1, =coo Co SSA yte)nate 412Yertiel ravAH24
Maootn batto CMS
TO BE COMPLETED BY PERSONNEL OFFICE 4. NAME (Last Past. abaft =al 5. SOCIAL SECURITY 0. SUBMISSION DATE
Li CONTROL NUMBER a TYPE OF ACTDN
0 1Crypol 0 2 Ck-
ace Nice 1— .7 -O\let . t 0.2.6-1%
CURREY! RESIDENCE ADDRESS FOR TAX PURPOSES
PRVACY ACT STATEMENT: RESDEN0E ACIULESSI AUTHOR110*: Vat Soolcm SSA 8817UM Si20 a Soc0x0 1ca810, 2. INPPOSE AND L.Se Toemol Co wan
rop-tormea of Far* Sala alt SRNs a. I CONOntro a/ cramRegarmMaw 4 WOMAN . Faro mama Co armr1Reave
Aril MCM141011,4 tmtdeon dtbo dad aCtrasat past04 preen as
proscacenvrox
7. STREET ADDRESS (No., Niers, St. Dr., PL, ce.)
8. t3EQGMD UNE STREET ADDRESS CS nacessary) "-%
Jorei eW t a) reini xTRy
9. CITY 10. COUNTY OR FOREIGN 11. sratEj 12 ZEP .
.. IM-
CURRENT RESIDENCE ADDRESS AND TELEPHONE NUMBER
POMO' ACT STATEWHiT: RESDEACE N=RESS ARIDTEXPCNE MASER-1. AUTHORTIY: a USC Sxoon SOY 2 RRPOSE No LSE To OW= 400430:03 SUS cooboTte 01COn elm
00621raw *am to ostroTroloTTSC sch or Copra. it Ann Amen to et 000Tmeathaltmallot.oarpbstb oupentsc0 OR ran-ts rated by the Fambn). a EFFECTS OP
10244TISCADSURE: tAdrrsati dym Co b VCIMNTARY. b to= to rot kart* avor4407 rov 1R1T41 lava fl MoTTTIS 4"1:4100 44 to fen of cranny *a Can
TELEPHONE It ECM'S()NO any) TO BE COMPLETED BY PERSONNEL OFFICE.
NUMBER 10. LOCATION CODE OP RESIDENCE I
17. MAY THE BE USED TO CONTACT YOU ON MATTERS RELATLSG TO YOUR EMPLOYMENT %MTh THE
DEPARTMENT OF
TM ❑ c
WASKILOTON. DC METROPOLITAN AREA EMPLOYEES ONLY-COMMUTER CLUB (CAR POOL) INFORMATION
PRVACY ACT STATEllata: 1. AUTIORrrY. Rao ro array uLtaty Or To 010 01at Kenyon b area Ccoarlot d JA:co 0T007401h ma Canes 0144 Ito Grano Q,ab Won , ma
awn= ty to Maw= WaTtlatmElcan arTna trtorrnaTcn Aomori to CorcuMrCbt Warta-4V b T4R:Rol 010MINTART tots by eat: erre. 2 MVO:ISMO ME: To rains
en:bp:of tehus etpaws •toNe yi clot Fccfrrty s Nennor p-1:01el VOLUNTARY peen oin Caren rL7etwa cm40 L On arvlopoNs rem tab otlysi, retort (400/0) ante
adlon.mmMinn) rant Gprattnota watt tlein r-ccro 00.4211 ErtpkAvo La:rox Ors 4. t L 0. 12 11,12 IAffi, 31. 4,41,424 Qs ,rd 481bdOrib Cn CoTrutfCtin a.zzgazd
data Stoaslyi rystrrt eta 0=troteratron tech=arm Aso, =Royer (esexyl end cam teleytere nab& CY= Da.4.21:1 Erticbree LOSCr sore A 5347. all AS) 1 EFPECTSCR MDR,
WI: MO:a= al Ols tkrtrubib VOLUNTARY. Idliro b &wino *42 ,rad h umbra MIbeing a (maxi d To Oranmm cn:lholy% it crOona Worryfon eV to 10113 Co
CaG
IS. WASHINGTON, CC METROPOLITAN AREA EMPLOYEE-SC/4LT V ❑ Yet.-, ion to w re cm:7cm=
N 0 Ratty,my rant as proamIGNaTralon tan OsCecron-VCIth
St you aro not In torostod In 1M Commu for Club, skip Silo q uo r on).
R 0 Wspal fecal -I an 0 CaraltrCZ MCctat and want en Wad Ce;TallrtiCI:at%
EMERGENCY LOCATOR INFORMATION
PI VACYACT STATENDIT: Bekaa' LOCATOR-1.411MORnY: e use. soczas S01 CCno. 2.Rama moLSEToga& craws/ trcCer4 ors met LINO mSA* Si 20meld
Cardcwo, t-inrcr Dana a /44.L. TS CF NONIMICU)StOM140=Inkri a/ 0a aY b VOLLZMWY =dada. Oar to ernlorech .at, aa Marto-01
PERSON TO BE sorra) IN EVENT OF EMERGENCY L3 PERSON TO BE NOTIFIED IN EVENT OF EMERGENCY
30. ORGANIZATION NAME
37. BUILDING NAME 2/' any) 38. ROOM NUMBER
39. STREET ADDRESS
40. CRY 41. COUNTY OR FOREIGN COUNTRY Al STATE 42. 21P CODE
TELEPHONE 48. AREA 47. SEVEN DIGIT NUMBER 46. tXTENSION(7 cry,
L4 FRS DYES ONO
NUMBER CODE
a NON FTS, UST AREA COTE
PERSON TO BE MOTIFID IN EVENT OF EMERGENCY 82. BUILDING CODE It ECIENS334loreey)
FORM 00.1.79 ARON
EFTA00036380