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
14. Place of Emplyment if presently emplyed University or school if student
15. Position
16. Description of work
17. FOREIGN TRAVEL
Have you ever lived or traveled through any foreign city/states throughout the Continental United States? explain in detail)
17. SPECIAL QUALIFICATIONS AND SKILLS
A. Licenses or certificates
E. Special skills you possess and machines and equipment you can use
F. Special qualifications not covered in application (For example, your most important publications; your patents or inventions; membership in professional or scientific societies, etc.; honors and fellowships received.)
21. EDUCATION
A. State major field of study at highest level of education
B. Most enlightening revelation brought about through highest level of education (in less than five words please)
C. Most enlightening regulation maintained by educational facility (use as many words as you please)
TRUE OR FALSE -- PLACE X IN PROPER COLUMN -- YES - NO
23. Have you ever had a nervous breakdown?
25. Have you ever had an allergic reaction to pemiculin?
26. Have you ever been arrested, taken into custody, held for investigation or questioning, or charged by any law enforcement authority? (Do not omit: (1) Traffic violations for which you paid a fine of $30.000 or less, (2) Minor petty larcenies, (3) Major petty larcenies, (4) Anything that happened before your 6th birthday. All incidents must be included, even though they were dismissed or you merely forfeited collateral.)
27. While in the military service were you ever arrested for an offence which resulted in a trial by deck court or by summary, special, or general court-martial?
If your answer to 26, or 27, is "yes" give details in item 39, showing form each incident (1) date, (2) charge, (3) place, (4) law enforcing authority or type of court or court-martial, and (5) action taken.
28. Furs are articles made of fur on the hide or pelt and articles of which such fur is worth more than three times as much as the next most valuable component.
29. The first digit of my area code is 6.
30. A citizen of Pennsylvania may sue the state of New Jersey in a federal court.
31. Considering the average for my sex I wear my hair.
32. The most unusual film on our program , now or ever, is Ted Browning's FREAKS. Browning, a master of the macabre, created the imperishable Dracula with Bela Lugosi and The Unholy Three with Lon Chaney.
33. Mothers is good.
PERSONALITY TRAITS
34. My favorite kind of ravioli is
35. My favorite hobby is
36. My favorite music is
37. Favorite color
38. Favorite smell
39. My favorite confrontation with authority
40. My favoritest place
41. Favorite contemporary artist(s) Visual, environmental or cinema
42. Favorite predecessor
43. Favorite Dadist and/or surrealist
44. Favorite contemporary musician(s) group(s)
45. Favorite well known personage
46. Favorite movie
47. Favorite form of recreation
48. Favorite flavor ice cream if you don't like ice cream your favorite piece of apparel
49. Fave rave
50. Favorite other stuff
SPACE FOR DETAILED ANSWERS TO OTHER QUESTIONS. Indicate item numbers to which answers apply.
Signature (sign in ink) Date
