Approved For Release 2001103/07 : CIA-RDP96-00789 100"
   RP@ Z " /
   STATEMENT OF CONSENT
   it- J O-S4 5 q// 40, N, r, o w 0 A, @ 5A Gas a participant in the INSCOM
   GRILL FLAME Project (IGFP) do hereby give my consent IAW AR 381-17 to the
   tape recording, monitoring and transcribing of all session interviews
   conducted as an integral part of the IGFP. I understand that all of my
   session interviews are tape recorded. I further understand that these
   tape recordings are subject to being monitored and/or transcribed by third
   parties not otherwise involved in the session interviews.
   In conjunction with my consent to the above, I also waive any claim or right
   of ownership to all tape recordings, and transcripts made, or which have been
   madeq in conjunction with IGFP. I understand that these tape recordings
   and transcripts are the property of the United States Government.
   I execute this written consent to formalize my previous verbal consent to the
   above; having given my verbal consent to the above when I became a partici-
   pant in the IGFP.
      DATA REQUIRED BY THE PRIVACY ACT OF 1974
   (5 U.S.C. 552a)
   1. Authority: National Records Act, 44 U.S.C. 3102; E.O. 9397, Numbering
   System for Federal Accounts Relating to Individual Persons, November 22, 1943.
   2. Principal Purpose: To maintain a record of those individuals who have
   consented to the recording, monitoring or transcribing IGFP.session interviews.
   3. Routine Uses: The Social Security Number is to be used to identify Lhe
   individual, and the information is to be retained strictly,within the Program.
   4. Mandatory or Voluntary Disclosure: Information is disclosed on a voluntary
   basis, but withholding information will render it impossible to grant an
   individual access to or participation in the Program.
   WITNESS: SIGNED:
   SGFOIA3 /V 4@7
   Name, Rank/Grade Prameg@ftank Grad
   Social becurlLy i,4umuer
          SGFOIA3
   t)UClal Z3eCUr1Ly iNiumber
   JS L.->/ P
   @@ 'W2_' 6e
   Unit/Organization
   @@ X'1211@04
   Poeition
         W/A)S6W
   Uhit/Organization-
   Positicfi
   Approved For Release 2001/03/07 CIA-RDP96-00789ROO2100150010-2