FORM APPROVED
BUDGET BUREAU No. 23-R045-43

SELECTIVE SERVICE SYSTEM

[box]
(LOCAL BOARD DATE STAMP WITH CODE)

STATEMENT OF UNITED STATES CITIZEN OF JAPANESE ANCESTRY

-----------------------

1.______________________________


_____________________________


_______________________________
(Surname)


(English given name)


(Japanese given name)

(a) Alias ________________________________________________________________________________________

2. Local selective service board ______________________________________________________________________

(Number)
_______________________________________________________________________________________________
(City) (County) (State)

3. Date of birth __________________________________ Place of birth ______________________________________

4. Present address _____________________________________________________________________________
(Street) (City) (State)

5. Last two addresses at which you lived 3 months or more (exclude residence at relocation center and at assembly center):

_______________________________________________________________ >From ___________ To ____________

_______________________________________________________________ >From ___________ To ____________

6. Sex _________________________ Height _________________________ Weight ________________________

7. Are you a registered voter? _________________________ Year first registered _____________________

Where? ________________________________________ Party _________________________________________

8. Marital status _________________ Citizenship of wife _______________ Race of wife ________________

9.____________________________________________________________________________________________
(Father's name) (Town or Ken) (State or Country) (Occupation)

(Birthplace)

10.___________________________________________________________________________________________
(Mother's name) (Town or Ken) (State or Country) (Occupation)

(Birthplace)
In items 11 and 12, you need not list relatives other than your parents, your children, your brothers and sisters. For each person give name; relationship to you (such as father); citizenship; complete address; 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) (Volunteer or selectee)
(b) ___________________________________________________________________________________
(Name) (Relationship to you) (Citizenship)
___________________________________________________________________________________
(Complete address) (Occupation) (Volunteer or selectee)
(c) ___________________________________________________________________________________
(Name) (Relationship to you) (Citizenship)
___________________________________________________________________________________
(Complete address) (Occupation) (Volunteer or selectee)
(If additional space is necessary, attach sheets)

12. Relatives in Japan (see instruction above item 11):

________________________________________________________________________________________________
(Name) (Relationship to you) (Citizenship)



________________________________________________________________________________________________
(Complete address) (Occupation)



________________________________________________________________________________________________
(Name) (Relationship to you) (Citizenship)



________________________________________________________________________________________________
(Complete address) (Occupation)

13. Education:

Name Place Years of attendance



___________________________________
 ____________________________ From ___________ To ___________
(Kindergarten)




___________________________________ ____________________________ From ___________ To ___________
(Grade School)




___________________________________ ____________________________ From ___________ To ___________
(Japanese language school)




___________________________________ ____________________________ From ___________ To ___________
(High school)




___________________________________ ____________________________ From ___________ To ___________
(Junior college, college, or university)




________________________________________________________________________________________________
(Type of military training, such as R.O.T.C. or Gunji Kyoren) (Where and when)



________________________________________________________________________________________________
(Other schooling) (Years of attendance)

14. Foreign travel (give dates, where, how, for whom, with whom, and reasons therefor):

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

15. Employment (give employers' names and kind of business, addresses, and dates from 1935 to date):

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

16. Religion: _________________________ Membership in religious groups __________________________

________________________________________________________________________________________________

17. Membership in organizations (clubs, societies, associations, etc.). Give name, kind of organization, and dates of membership.

________________________________________________________________________________________________

________________________________________________________________________________________________

18. Knowledge of foreign languages (put check mark in proper squares):

(a) Japanese Good Fair Poor

(b) Other _______ Good Fair Poor






(Specify)


Reading [ ] [ ] [ ]

Reading [ ] [ ] [ ]
Writing [ ] [ ] [ ]

Writing [ ] [ ] [ ]
Speaking [ ] [ ] [ ]

Speaking [ ] [ ] [ ]

19. Sports and hobbies ________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

20. List five references, other than relatives of former employers, giving address, occupation, and number of years known:

________________________________________________________________________________________________
(Name)
 (Complete address) (Occupation) (Years known)
________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

21. Have you ever been convicted by a court of a criminal offense (other than a minor traffic violation)? __________

Offense
 When What court Sentence
________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

22. Give details on any foreign investments.
(a) Accounts in foreign banks. Amount, $__________

Bank ______________________ Date account opened ______________

(b) Investments in foreign companies. Amount, $__________

Company ___________________ Date acquired __________________

(c) Do you have a safe-deposit box in a foreign country?

What country? ______________ Date acquired __________________

Contents _____________________________________________________________________________
23. List contributions you have made to any society, organization, or club:

Organization
 Place Amount Date

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

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 governmental 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)
When? ___________________________ Where? ________________________________

26. Have you ever applied for repatriation to Japan? ______________________________________________

27. Are you willing to serve in the armed forces of the United States on combat duty, wherever ordered? __________

28. Will you swear unqualified allegiance to the United States of America and faithfully defend the United States from any or all attack by foreign or domestic forces, and forswear any form of allegiance or obedience to the Japanese emperor, or any other foreign government, power, or organization? __________

_____________________________________





__________________________________________
(Date)





(Signature)

NOTE: -- Any person who knowingly and wilfully falsifies or conceals a material fact or makes a false or fraudulent statement or representation in any matter within the jurisdiction of any department or agency of the United States is liable to a fine of not more than $10,000 or 10 years' imprisonment, or both.

DSS Form 304A
(1-23-43)
U. S. GOVERNMENT PRINTING OFFICE 16-3265-1
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