Life History Form

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Beverly Rice

Oct 12, 2002, 1:18:22 AM10/12/02
How many of the ex-members of Co$ had filled out this form?

Between all the forms that must be filled out and given to
the Co$ for their files, and the sec-checks done on members,
and the ethics folders filled with KR's . . .

it's no wonder so many when they leave choose to remain

I guess the sec-checks and Life History Forms could also be
adequately called "Pre-Planned Blackmail" :-(

Thanks to Warrior for making this one known.

If anybody else has any of the forms Co$ requires you to fill
out that are overly invasive in to your personal life or history,
please, ~please~ post them.

It is good to have all of this in a public forum and available
for public consumption, and also on a medium like the internet to
be stored for posterity.

Why, storing it on the internet is ~almost~ as good as having
it stored in multi-hundred million dollar underground vaults. :-)

Life History

Name: _______________________ Date ________________________
ASHO D Post ________________________
(Answer questions on separate paper and attach)


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 squirrel 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,

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, and 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.


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.)

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.

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 where done.

5. Please list your parents' names and adresses (or

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 their job history is, where
they live and with who. What is your attitude towards

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
A. Intelligence organizations
B. Organized medicine
C. Banking industry
D. The Media
E. Goverment
F. Public Relation Firms
G. Psychiatry, psychiatrists, 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.


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?


If you are in the SO put down your rank and rating.
Sea Org Training? (include date) AB, SWBP, SOSS, PROD
0,I,II,III ore more?
What class missionaire? 3rd, 2nd, 1st? Are you mission

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.)

Please attest the data is true and correct.

ARC = As-Ising the Real CST,


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