Fort Worden Oral History Program
Fort Worden History Center
Fort Worden State Park Conference Center

Biographical Data Form

For Veterans, Their Family Members,
Juvenile Diagnostic/Treatment Center Participants
and State Park Interviewees

NAME:___________________________________________
ADDRESS:
Street____________________________________________
City_____________________________State____Zip_____
TELEPHONE:______________________________________
DATE OF BIRTH (mo/dy/yr):___________________________
PLACE OF BIRTH:
City________________________State____Country________
Dates of Fort Worden connection:_______________________
Description of Fort Worden connection___________________
__________________________________________________
If Military:
Branch of Service_____________________
Particular Unit_______________________
Dates of Service______________________
Highest Rank Achieved_________________
Locations of Service__________________
POW? ______Yes ________No
Medals, Citations_____________________

Do you have _____ photos or _____ manuscript materials to share? (Please check to indicate).
If so, do you want to donate the originals to the Fort Worden archives? _____ Or would you prefer
that the Fort Worden Oral History Program scan them into the computerized database and return
the originals to you? _______