| Relocation Center_______________ |
|
|
| Family
No.____________________ |
|
|
| Center
Address________________ |
|
|
| |
| 1.
____________________________________________________________ |
| Surname English given name Japanese given name |
| (a)
Alias _________________________________________________ |
| 2.
Names and ages of dependents you propose to take with you_________ |
| ______________________________________________________ |
| 3. Date of birth |
______________ |
Place of birth |
______________ |
| 4.
Citizenship __________________________________________________ |
| 5. Last two addresses at which you lived 3 months or more (includes residence at relocation center and at assembly center): |
| _________________________ From:
___________ To:
___________ |
| _________________________ From:
___________ To:
___________ |
| 6.
Sex ____________ Height
____________ Weight
___________ |
| 7.
Are you a registered voter? ________ First
year registered? _________ |
Where?
________________ Party?
________________ |
| 8.
Marital status _____________ Citizenship
of spouse _____________ |
| Race
of spouse ___________ |
| 9.
_____________________________________________________________ |
| Father’s name Birthplace: Town or City State or Country Occupation |
| 10. ____________________________________________________________ |
| Mother’s name Birthplace: Town or City State or Country Occupation |
| |
| In items 11 and 12, list relatives other than your parents, your children, your brothers and sisters. For each person, give name, relationship to you, citizenship, complete address, and occupation. |
| 11. Relatives in the United States (if in military service, indicate whether a selectee or volunteer): |
| (a)_____________________________________________________________ |
| name relationship to you citizenship |
| _______________________________________________________ |
| complete address occupation selectee or volunteer |
| (b)_____________________________________________________________ |
| name relationship to you citizenship |
| _______________________________________________________ |
| complete address occupation selectee or volunteer |
| 24. List magazines and newspapers to which you have subscribed or have customarily read: |
| _______________________________________________________ |
| _______________________________________________________ |
| 25. To the best of your knowledge was your birth ever registered with any Japanese agency for the purpose of establishing a claim to Japanese citizenship? |
| (a) If so registered, have you applied for cancellation of such registration? |
| yes
or no If so: ___________ When? ___________ Where?___________ |
| 26.
Have you ever applied for repatriation to Japan? _____________________ |
| 27.
If the opportunity presents itself and you are found qualified, would
you be willing to volunteer for the Army Auxiliary Corps or the WAAC ___________ |
| 28. Will you swear unqualified allegiance to the United States of America and forswear any form of allegiance or obedience to the Japanese emperor, or any other foreign power, government, or organization? |
| _______________________________________________________ |
| 29. Have you ever worked for or volunteered your services to the Japanese or Spanish government? |
If so, indicate which and give dates: |
| _______________________________________________________ |
| 30. Have you ever registered your children with a Japanese or Spanish consul? |
yes or no If so: |
| Names Dates Names Dates |
| _______________________________________________________ |
| _______________________________________________________ |
| _______________________________________________________ |
| 31. Have you ever sent any of your children to Japan? _____ If so, give names and dates: |
| Names Dates Names Dates |
| _______________________________________________________ |
| _______________________________________________________ |
| _______________________________________________________ |
| 32. State any type of leave previously applied for and indicate whether leave clearance has previously been applied for, giving date and place of application. |
| _______________________________________________________ |
| _______________________________________________________ |
| 33. If employment is desired, but no definite offer has been received, list the kinds of employment desired in order of preference: |
| First
choice: ____________________________________________________ |
| Second
choice: _________________________________________________ |
| Third
choice: ____________________________________________________ |
(a) Will you take employment in any part of the United States? |
yes
or no ___________________________________________________ |
(b)Location
preferences _______________________________ |
| ___________________________ ___________________________ |
| date signature |
|
