Approved For Release 2001/03/07 : CIA-RDP96-00789ROO210015003 -0
                    Date 1V6
     STATEMENT OF CONSENT W
     as a participant in the INSCOM
     GRILL FLAME Project (IGFP) do hereby g@ive my consent IAW AR 381-17 to the
     tape recordingt 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
     made, 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 the
     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:
                                     -1 qlw@" ZZ C.
                                    Nam , Rank Grade
     Social Security Number
     M,@ e, S 0 PJ - 144J m "v ?_
     4t, W'r ve, k rv r' 4-s V%..'
     Unit/Organization
     45peu J 44,04
     ;'(f jr
     Position
     SIGNED:
     C5_ r@A 0.0*
     Name, Rank/Grade
     SGFOIA3
     SGFOIA3 5ocial Security Num1ber
     Unit/Organization
     AA P/ e
     Position
     Approved For Release 2001103107 : CIA-RDP96-00789ROO2100150030-0