Strunk Response 1

TO BE COMPLETED BY AN APPLICANT WHO BECAME A CITIZEN THROUGH NAftlRALIZATIOM
lMMlG RATED T3 f HE r RESIDED CONTINUQCjSLY IN TuE NATclR 1LIZATION CERf 4 FICA7 E NO.
J.S. (Monrh, year) U.S. From (Year) To (Year) 0 Subm bed hermlm
I2 Ssen and returned
Previou~ly subrnltred
'LACE HATURALISEU (Citv, statel U2ilJR'ALlZAT13N COURT
I
IDATE NATURALIZED
TO BE COMPtEf ED BY ALL APPLICANTS
3CCUPATION
PROGRAM OFFICER, FORD FOUNDATION
VISIBLE DtSTIIVGUISHIb4G MARKS
-EN W T a P m E WLLOYVlNG fF CHILDREU OF A PREVIOCR MARRIAGE ARE WLUPED OR 1F PR€VW.SlY WRED BEFORE WW3" 1931
I WAS PREVIOUSI,Y MARRIED ON \TO (Fult legal name)
(WHO WAS BORN AT (City, St*, Countrv)
none
-
.
ON (Date of bimh) [I FORMER HUSBAND WAS U.S. ClSlZEN [PREVIOUS MARRIAGE TERMINATED BY a DEATH DIVORCE
I FORMER HUSBAND WAS NOT U.S. CIRZEN lol~ ID-,
~ ~ N P L ~ I F A F P U C A N F D R A N Y P E ~ ~ ~ ~ ~ N ~ I D N B W P S N O T ~ N I W ~ U
€+If EAED THE U.S. {Mon~h) (Year) IF FAT HER NATURALIZED: I IF KNOWN, FATHER'S RSIDENCE
PHYSICAL PRESENCE 1N U.S.
0 Applizam
Date
Certiflcats No.
From (Year) fa (Year)
W~B
13 Husbsnd
Before ( Nm of Court)
Place IClty, Stme)
Child
RESIDP~~~CE/CONTINUOUS PHYSICAL 1F MOTHER NATURALIZED: IF KNOW, WTHEUS RESIDEME
PRESENCE IN U.S. Fr~rn(Ysarj To (Yssr)
PHYSICAL PFlESENCE IN U.S.
Dete
Certificate No.
Appliant Fmm IYeer) To 1Year)
7 I I I I
1
I INTEND TO CONTINUE TO RESIDE ABROAD FOR THE FOLLOWTNG PERrOD AND PURPOSE
Two years contract with Ford Foundation from January 1981 - December 1982.
II~TENDTORETURNTDTHEUNITEDSTATESPEAMANENTLV
DATEOFDEPARTURE
4 YEARS MONTHS
1 PRlVACY ACT STATEMENT
T& Information snlieln?d an this fdm is authorized by but not limited to, tho= statutes codified In Titlm 8, 18, and 2% 4JnimdSt.TosCodq md *I1
pmdecmsor rt;lu.ttes wketker or not codified, and s)t re&lation$ issued pursuant to Ewmcutiue Drhr 11295 of August 5, 1966. The p r l m put'PUM ~ ~ for
.ollciting the information Is to esrablish citizenshipr Identiq and entitlmem to Issuance 8+ a Unlwd States Pmpon or raja& ftsllity, and to prupetly
admlnisrer and enforce tha Ems psrtaining rherato.
The infomatian ismade available as a routine urn on a need-*know ba~k te psrs~nnel of the Chpartment of S m and ethw gwwnmmnt agenele~ hwlng
statutory or other lewful authoriw to maintain mch information in the perfmmanfa af their officlal dutias; purarantm ambpoenr 8r court ardor; and,
~s sat forth in Parr 64 Titye 22, Code of Federal Regukitions {Sea Federal Register Volume do, pages 45755, 45156, 47419 and 67420).
Failure t8 prwids the lrrfwmffio~ requested ~xr this form may rmlt In the denial of a United Srateo Pwort, rel~t9d docurnant or 5 a ~ k O tO h6
indlvldusl seeking wch psgspoq docwmenr Qr service.
NOTE: The dischsurs of your Sacial Security hlurnbw or d the identin, and locattan r~f a p e m tm bs no~ifisd In thm went Of dmath mT rcidmnt JI
entirely voluntary. H owwwr, failure to pmvida this in+wmadon may prwent the Depanment of State frm prwiding yw wWh rlmely armlstance or
promtion in the went you shwld anceunrer an emergency siruae-1 whFle oumlde The United Stams.
ACTS OR CONDITIONS
(IF m y of me baluwmentioned acts or conditions have bmn parfwmed by er qply to the applieanf or to any other p-n ta bn lncluded in thm
passport, the pOrtIcxl which appli- should be smck out. and a supplemenmry e*otanatnry statement undw oath (or affirmation) by tke par-n to whom
the partion is applicable should be attsched and made a part af fhiq application.)
1 have not (end no other wrron included in ?his appllcatlan has}, since acqulrlng Vnimd S- citizenship, m n naturatizedas a citlren M afwoign m;
taken an ash Or made an affirmation or oMsr formal declaration 07 allegiance m aforegn stare: enrered or mwud In the armad forcm nf sforeinn smm;
acepted or performed the dutiee of any office, post, or employment under the govwnment of 8 forelgn rtam or political subdivl~ion thererrf: made s
fo~rnat ranunclatiun of nationality either in the United S tams or bdore a diplomatic or conwlar officer of the United Staas in a toreign State; svsr WQht
or claimed the twnefirs of the netionaliry of any foreign %taw: or been convicted by a court or court rnartlal of compefant jurisdiction committing anv
a ~ of t meason aga;nst. or atrsmpting by force to overthrow, or beaing arms ageinst, t,a UniTed Stares, or conspiring to ovmrthrm, put down or to
desnoy by force, rhe Government of rhe United States
Wk RNING: False starementr made knowingrv and willfully in pasport applicwions or in aFTi&vits Or rimer flupporting doturnsnu rubrnltQd Therewith
are punishabla by five and/or imprlwnmenr under the provisions uf 18 USC t Wl and/or 18 USC 7542. Alteration or rnurilalon of a paaaort Imnd
pursuant to this application is punishable by fine and/or irnprlaonmsnt under the pmvisians of 18 USC 1563. The use of a pawart in wiolstim Of the
restriction5 contained therein or Of the pasport regulations is punishable by fine and/or imprisunment under 18 USC 1544. A lr stetemmts end
documents submirwd are rubjeet m verificaricn.
--
~PPL~CANT'S IDENTIFYING OOCUMENT~I
CeMfieate of Naturallzation
or Citizenship No.:
U PBSSPOTT 1 ~ Dm: ~ 9
Urivefs Liceme
Place of Issue:
Tthur lSc;acifyJ:
!$mud In Name OE
IFOR USE OF OFFICE TAKING APPLlCATlONl
I DENT IFYlNG DOCUMENT lS) OF WIFEIHUSBAFTD T 0 BE INCLUDED
IN PASSPORT
Certificam of Naturalizarion
or Cirirenshlp No.:
Passpart
lreue Oa*:
, n Driver's License Plaee of !we:
C] 0rhet (SP~CWY): lasued in Name of: