The Fanzine Questionnaire
DATA FOR SENSITIVE OR CRITICAL-SENSITIVE POSITION
IMPORTANT: INSTRUCTIONS
This form must be completed in duplicate. Use dark legible pen or typewrite if possible. Make sure all questions have been answered to the fullest extent of your memory's capacity and/or imagination where applicable. Complete all items except No. 28. If an answer to any item is "no" or "none" so state. Any items that for personal reasons you wish to remain confidental leave blank.
Item 17A. pertains to type of licenses or certificates in possession.
After you have filled out this form in duplicate place one copy with your records in a safe place and send the other copy to United Mutations, Box 23315, Hollywood, California 90028 along with a suitable photograph or photographs and any other material which you feel may be necessary.
1. Photo
2. Social Name
3. Name at birth (First, middle, last)
4. Address of correspondence (Number, Street, State, and Zip code)
5. Home phone No.
6. Height
7. Weight
8. Sex
9. Marital status
10. Birthplace
11. Birth date
12
13, Profession If student so state
