Name: _______________________ Date    ________________________
                                   today:
     ASHO D                        Post    ________________________
     AOLA
             (Answer questions on separate paper and attach)
 

    PART I
 

      1. Do you have a psychiatric/institutional history, or have
         you ever been a social worker, psychologist or counselor
         of any kind? Have you practiced any kind of group therapy?
              A. If yes to any of the above, give time, place,
              form, event and full details.
 

      2. Have you ever had a willing connection to a squirrel group
         or suppressive group?
              A. If yes, give full details.
 

      3. Have you ever blown from any Scientology or Sea
         Organization? (even if only for a day)?
              A. If yes, give full details.
 

      4. Are you connected to anyone antagonistic to Scientology?
              A. If yes, give full details.
 

      5. Have you ever threatened or attacked Scientology?
              A. If yes, give full details.
 

      6. Have you ever been expelled from the Church?
              A. If yes, give full details.
 

      7. Do you have a criminal history of any kind?
              A. If yes, give full details (time, place, form,
              event).
 

      8. Have you taken illegal drugs?
 

      9. Have you completed the Drug Rundown? When?
 

     10. Have you ever taken drugs since being in Scientology?
              A. If yes, please state what drugs you took, and what
              training and/or auditing you'd had, when and where
              and under what circumstances you took the drugs.
 

     11. Have you ever threatened or attempted suicide?
              A. If yes, please give full details.
 

    PART II
 

      1. SCIENTOLOGY AND DIANETIC TRAINING.
         Please list in chronological order exactly which Tech and
         Admin training you have done. List should be date of
         completion, Month and year. (For any courses not
         completed, please give the date you started the courses
         and note that they are incomplete.)
 

      2. PROCESSING.
         Please list in chronological order exactly what processing
         you have had. Give the date (month/year) you completed all
         actions and the date of starting any action which is not
         complete. Include OT sections and any major rundowns.
 

    PART III
 

      1. When and where were you born?
 

      2. Education: Please list in chronological order, beginning
         with your earliest schooling, every school you have
         attended. Use the headings as illustrated below.
          DATES       NAME OF SCHOOL   LOCATION   MAJOR STUDY
 

      3. Employment: Please list in chronological order all jobs
         you have held beginning with your first job. Please
         explain what you were doing during any period of
         unemployment. Use headings.
 

      4. Medical history: Please list in chronological order any
         illness, accidents, permanent injury, etc, you have had,
         from birth to PT by month and year. Include all childhood
         illnesses (i.e. mumps, measels, chicken pox, etc). List
         the names and location of any hospitals and sanitoria you
         have been in. State also the approximate frequency that
         you have had colds, aches and regular pains during your
         life, with the time periods. List also any corrective
         surgery you have had and where done.
 

      5. Please list your parents' names and adresses (or
         guardian).
 

      6. Please list your parents' PT occupation, and any other
         jobs they might have held. Give a brief description of the
         type of work they did, the name of the corporation, etc.
 

      7. What is your attitude towards your parents, and what do
         you think of them? How do they regard you?
 

      8. Please list the names and adresses of your brothers and
         sisters (if any), and what their job history is, where
         they live and with who. What is your attitude towards
         them?
 

      9. List your friends (even prior to Scientology) and what
         sort of relationship you had, and what sort of jobs they
         held and are holding now. Also please state what your comm
         has consisted of since being in Scientology.
 

     10. What is your marital status? Please list the name of your
         present spouse and any past spouses (in chronological
         order if more than one), when you married him/her and
         where. List also the dates of any separations and/or
         divorces and why. (Give month/year for all dates and
         maiden names where applicable.)
 

     11. Give a general 2-D history for yourself, including your
         earliest sexual experience of any kind, when you started
         dating, and the names of all persons involved. Make a
         chronological list by month/year of the names of all
         persons with whom you have had sexual relationships and
         what you engaged in. Approximate the number of times you
         carried on any kind of activity, and note any perversions
         you engaged in: WHO, WHAT, HOW OFTEN. Be as complete as
         you can.
 

     12. Note any instances of homosexual activity from earliest
         time to PT. Give WHO, WHAT and HOW OFTEN.
 

     13. List names and ages of children you have.
 

     14. List your interests and hobbies.
 

     15. List all groups and organizations you have ever been
         associated with. Include time period, name of group, its
         location, what type of group, and what you did in it.
 

     16. List any connections to terminals listed in the following
         groups.
              A. Intelligence organizations
              B. Organized medicine
              C. Banking industry
              D. The Media
              E. Goverment
              F. Public Relation Firms
              G. Psychiatry, psychiatrists, psychologists, etc.
 

    PART IV
 

      1. How did you get into Scientology? Include who introduced
         you, where and when and what this person is doing now.
 

      2. When and were did you first start on staff in a
         Scientology mission or organization?
 

      3. Please list in chronological order all posts you have held
         in any Scientology organization and mission. Use headings.
 

      4. Please list any MAJOR ETHICS ACTIONS YOU HAVE HAD, good
         and bad, and explain it fully.
 

      5. To what org are you contracted and for how long?
 

    PART V
 

      1. Please list all drugs you have taken, including medicine
         with month/yr time periods as closely as possible. Use
         headings as in the illustration below.
          DATE          DRUG           APPROX # OF TIMES
 

    PART VI
 

      1. Please give exact details concerning your current life:
         whom you live with, whom you spent your free time with or
         run around with, etc. What is your daily routine, what do
         you do with your leisure time?
 

                                 -------
 

    If you are in the SO put down your rank and rating.
    Sea Org Training? (include date) AB, SWBP, SOSS, PROD
    0,I,II,III ore more?
    What class missionaire? 3rd, 2nd, 1st? Are you mission
    eligible?
 

    List out any missions you were on with what conditions and when
    that mission was. Also what position you held on the mission.
    (IC, etc.)
 

         Please attest the data is true and correct.