;
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.)