; Moy og Mano tary at the Preeifiea Trucnds, Delt. AP Hoekah Met. 2 Mookyee ty VT Poe. e Te OVO a EE ee PO ve i Tou pee moe VI oo Sa eee Sade 3 ive gdb bows Mt" Waoncra the. YOUR TITMEV EEBm MSS V1. SALARY” T bewausy DATE EMPLOYED OOO! Toei OD STEN - MONTHS IN ACADEMIC YEAR 12, PREVIOUS POSITIONS FOR PAST FIVE YEARS (INCLUDE HOSPITAL APPOINTMENTS IF ANY) (Nome and Address of Employers, Job Title, Salary, Dates of Employment, Reason for Leaving, Include Military Service if Pertinent} =e R. Papsielhens Meeievwl G@reun (Pr. PLilic 55L0 Los. Csayotes Dietinal, Lonz LeAck Services, Los Altas Stenital; Pacific, Pacr:), c/o Lees Altos Woele Cis, SOLOS; Director, Mrorceney *69,¢6 c0/yPes Nay 1G7k to Octater Le T) go sotlins in the Scuth sth B tan heeBhiueaiDaaet ici ee SE SARS 10. PRESENT AFFILIATION NAME AND ADDRESS ‘ PRIVACY ACT MATERIAL REMOVED \ecist Prof MedicinesMey 1962 to August 1973, Walv Sovthern Calif, Sc! 9cl of Mediicise: 757,000; Loft at camvlctinrn «7 20 yrr County ervice to 7s erwisins entlans). 13. REFERENCES (Name, Job Title, and Present Address of Three or MMore Persons Qualified to Evaluate Your Ability, Character, eic.) Paul M. Bcisolmcrn, . a > Frof Med., Dal fer Be Roynolds, M.°., Nobt. FE. Trancurda, Prilin Fagen, 1.7.5 Mh. 2, m2, Prof ted, Pref Ned, LAc-USS 2C, |" Assoc. Payee. one Moe. " Dean, 29°75 Zinol Ave., It. " " UCLA iel Canter, W Lis. Trovny, cee abate 14. STATE NATURE OF ENERGY RESEARCH AND DEVELOPMENT ADMINISTRATION CONTRACTS OR CLEARANCES, IF ANY, ANO CONDITIONS OF PREVIOUS APPOINTMENTS AT BROOKHAVEN «= ons 15. INFORMATION REQUIRED OF NON-IMMIGRANT ALIENS ONLY: 0 MALE] FEMALE [) b. MARRIED [] SINGLE [[] d. PLACE OF BIRTH {City} c. DATE OF BIRTH {Country} e. CITIZENSHIP f. TYPE OF CURRENT U.S. VISA HELD, IF ANY g. TYPE OF U.S. VISA YOU ARE CURRENTLY APPLYING FOR, IF ANY 16. ADDITONAL INFORMATION(If in reference to item,cite humber) ~ (Include Fellowships, Assistantships, Grant Awords, Reference to Publications, and Date Available for Employment} - PRIVACY ACT MATERIAL REMOVED (declare thot my answers to the questions and the statements moddoy “f an this form ore true angwa(hout comeqvential omissions of any hind. “ >Vin 4 a (Guz des| re Beek, .: ok) me useBeat, eae vbbOT | (This information form does not constitute an application for a visa.)