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1. When did you see the objects

1.1 Date: iad. igual cars
1.2 Time of day: —t- __- A.M. or(P.M) (Circle One)

1.3 Time Zone: (Cirole One):

Eastern 4. Pacific
e Central e. Other
Cc. Mountain

(Circle One): @ Daylight Saving

1.4 Cérale one of the following to indicate how certain you are
your answer to the above question 1.2:

Certain c. Not very sure
e Fairly certain ad. Just a guess

2. Where did you see the object?
k LA 4ul_ WAI
Soleo CA Ke ALLA el ee Maye te
3. Where were you located when you saw the object:
(Circle One): a. Inside a building ad. In an airplane

In a car e. At sea
Outdoors f. Other

3.1 Were you:
(Circle One): a. In
b. In
$s Flying
Flying

ly
g. Other

iness section of a city?
idential section of a city?
countryside?

an airfield?

a city?

open country?

ty
eit

d4i3

2-E7LE-L

4e How did you happen to notice the object?

Light AliaeTep Alar

5, When did you report to some official that you had seen the object?

Ge Cage {Ph

SECTION B

6 What were you doing at the time you saw the object?

. Si preg? rational

6.1 What had been doing for the 30 minutes before you saw the
object? to list the activity or activities, ani the

epproximate amount of time spent on each.

pe

7, Were you moving at any time while you saw the object? (Circle One):
lee or «(>
IF you answered YES, then camplete the follaving questions.
7.1 What direction were you moving?

(Circle One): a. North e. South
b. Northeast f. Southwest
o. East g. West

7.2 How fast were you moving? miles per hour,
7.3 Did you stop at any time while you were looking at the object?

(Circle One): Yes or Wo

Page 3

8, What direction were you facing when you first saw the object?

(Circle One): North ®. South
« Northeast f. Southwest
c. East g. West
ad. Southeast h. Northwest
8.1 What direction were you facing when the object disappeared?
(Circle One): @ North e. South
e Northeast f. Southwest
c. East . West
a. Southeast « Northwest

8.2 Circle one of the following to indicate how certain you are of
your answer to the above two questions, (8 and 8.1).

Certain 6. Not very sure
e Fairly certain d. Just a guess

9. Were you wearing eye glasses when you saw the object? (Circle One):
lee «6c 6D |
10, How was the object seen?
(Circle One): a. Through window glass e. Through theodolite

b. Through windshield f. Through sun glasses
c. Through binoculars @> Through open space
a. Through telescope . Other
11. What do you remember about the weather conditions at the time you saw
the object?
11.1 CLOUDS (Circle One) 11.3 WEATHER (Circle One)
a. Clear oS | @ Dry
« Fog, Mist, or light rain
c. Moderate or heavy rein
Soxttare or heavy ——_ ad. Snow
oa Don't rl = e. Don't remember
11.2 WD (Circle One) 11.4 TEMPERATURE (Circle One)
No wind a. Cold
« Slight breese b. Cool
c. Strong wind @ Warm
d. Don't remember de Hot

e. Don't remember

a _

Page 4

12, Estimate how the object? wm f-)
eh — ii ——ple ——

12.1 Girole one of the following to iniicate how certain you are of
your answer to Question 12:

« Certain 6. Not very sure
Fairly sure ad, Just a guess

13. Did the object look: (Circle One) Solid or Cfranspareng?
14. Did the object at any tine:
(Circle One for each ere

14.1 Change =
14.2 Change speed

14.3 Change a
14.4 ee Paar ies

we. FB =
2 & Eis

pulsate?
14.9 Remain motionless?
15, Did the object give off a light? (Circle One): Ges) Wo Don't kno
15.1 IF you ansvered YES, what was the color of the Light? Voky LighiG teen

16. Tell in a few words the following things about the object?
16,1 Sound VN owt
16,2 Color Cisg tT
17. IF there was MORE THAN CRE object, then hov many were there? mF

Draw a picture of how they were arranged, and put an arrow to
chav Go Civection They were Woveling.

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BA oniliany, Work sypond ote Uy nk and
Gf an a eranher wmckene Kthe halhioeh, Str

snd Atotacald Th; dnunLa, Suet yeroerd
Shlnles Sree wt Listy i

Page 5

18. Did the object at any time:

19.

21.

18,1 Move behind something? (Circle One) Yee iio) Don’t know
IF you answered YES, then tell what it moved behini.

18.2 Move in front of something? (Circle Ome) Yes (iis) Don't knoy
IF you answered YES, then tell what it moved in front of.

18.3 Bleni with the background? (Circle One) es lio) Don't know

Which of the following ob is about the same actual sise as the
object you saw? (Circle One):

a. Pea ? f. . Automobile
be Baseball Small airplane
6. Basketball cf Large airplane
ad. Bicycle wheel i. Dirigible

e. Office desk j. Other

19.1 Cirole one of the following to iniicate how certain you are
your answer to Question 19.

Certain c. Not very sure
e Veirly certain ad. Uncertain

Try to tell the following things about the object:

20.1 How high above the earth was it? Zi 00 _ feet.
20.2 How far was it from you?

20.3 How fest was it going? /@¢O _ miles per hour, Snue

20.4 Cirale ane of the following to indicate how certain you are
your answer to the above questions:

Certain é@. Not very sure
« Fairly certain 4. Just a guess

How did the object disappear fran view?

(Circle One): (a. Suddenly co. Other ___ me
» Gradually d. Don't remember

Page 6

i
ef

Horizon

Your eye

sketch place an "A" at the position the object was
when you first saw it, and a "B" at its position when you last sew it.

In the follow

Overhead

orizon

Horizon

Your eye

EE en ae

Page 7

25. Draw a picture that will show the shape of the object. Label and include
any details of the object that you saw, and place an arrow
beside the drawing to show the direction the object was moving.

" #

Hazy PariPh ERY

26. Was this the t time that you have seen an object like this?
(Circle One): No

26.1 IF you answered NO, then when, where, and under what conditions
did you see other ones?

27. In your opinion what do you think the object was and what might have
caused it?

No ConetivaAslea ber

28, Give the information about yourself:

=

Whet is your present job? Sates Receticatifies US CURR R Co.
Age 27
Sex a

Last School Attended _(diwehisly of M4 swt

Year of last attendance at this school __/ 74

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tie a_i

Page 8
29. Was anyone else with you at the time you saw the object?
(Carole One): (es) or fo
29.1 IF you answered YES, did they see the object too?

(Circle One)*(Jda or le
29.02 Please list their names and eddresses:

Wi Fe:

=

Houtionw, we.

30. Please add here any further comments which you believe are important.
Use additional sheets of the same sise paper if necessary,

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