Life History Form

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 suirrel 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, ad 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.

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.

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 were 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 thier 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, synchiatrists, psychologists, etc.

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?

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

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?

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Please attest the data is true and correct.

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.)