For use in Integrity Processing by a Hubbard Integrity Processing Specialist. See BTB 5 DEC 72 for procedure.

Auditor: ____________________________Preclear: _____________________________

Org: _________________________________Date: _______________________________

1. Have you ever lived or worked under an assumed name?_________

2. Have you given me your right name?_________

3. Are you here for a different purpose than you say?_________

4. Have you ever stolen anything?_________

5. Have you ever forged someone else’s signature?_________

6. Have you ever blackmailed anybody?_________

7. Have you ever done anything for which you could be blackmailed?_________

8. Have you ever smuggled anything?_________

9. Have you ever been in prison?_________

10. Have you ever indulged in drunkenness?_________

11. Have you ever done any reckless driving?_________

12. Have you ever burglarized any place?_________

13. Have you ever embezzled money?_________

14. Have you ever assaulted anyone?_________

15. Have you ever told lies in court?_________

16. Have you had anything to do with pornography?_________

17. Have you ever committed arson?_________

18. Have you ever been a drug addict?_________

19. Have you ever peddled dope?_________

20. Have you had any dealings with stolen goods?_________

21. Do you have a police record?_________

22. Have you ever raped anyone?_________

23. Have you ever been involved in an abortion?_________

24. Have you ever committed adultery?_________

25. Have you ever practiced homosexuality?_________

26. Have you ever had intercourse with a member of your family?_________

27. Have you ever been sexually unfaithful?_________

28. Have you ever made a practice of sexual perversion?_________

29. Have you ever slept with someone you shouldn’t have?_________

30. Have you ever committed culpable homicide?_________

31. Have you ever bombed anything?_________

32. Have you ever murdered anyone?_________

33. Have you ever kidnapped anyone?_________

34. Have you ever traded illegally?_________

35. Have you ever betrayed anyone for money?_________

36. Have you ever threatened anyone with a firearm?_________

37. Have you been in illegal possession of firearms?_________

38. Have you ever been paid for giving evidence?_________

39. Have you ever destroyed something belonging to someone else?_________

40. Have you ever been a spy for an organization?_________

41. Have you ever been an informer?_________

42. Have you ever been a member of an illegal organization?_________

43. Have you ever falsely reported?_________

44. Have you ever had intercourse while under the influence of drugs?_________

45. Have you ever had intercourse while under the influence of alcohol?_________

46. Have you ever used drugs or alcohol to procure sex?_________

47. Have you ever ill-treated children?_________

48. Have you ever taken money for giving someone sexual intercourse?_________

49. Have you ever had any connection with a brothel?_________

50. Have you ever gotten another into trouble for something you did?_________

51. Have you ever been a spy for the police?_________

52. Have you done something you are afraid the police may find out?_________

53. Have you ever falsified the books in any firm you worked for?_________

54. Have you ever disclosed confidential data?_________

55. Have you ever done anything your mother would be ashamed to find out about?_________

56. Have you ever purposely injured yourself?_________

57. Have you committed any overts against yourself?_________

58. Have you committed any overts against your family?_________

59. Have you ever harmed an organization?_________

60. Have you ever betrayed the trust of a group?_________

61. Have you ever killed or maimed animals for pleasure?_________

62. Have you ever mistreated animals?_________

63. Have you ever administered electric shock?_________

64. Have you ever tried to make someone insane?_________

65. Have you ever maliciously destroyed trees or plants?_________

66. Have you ever destroyed or damaged another’s property?_________

67. Have you ever taken part in sabotage?_________

68. Have you ever harmed a religion?_________

69. Have you ever persecuted another for their religious beliefs?_________

70. Have you ever violated the tenets of a religion to which you belonged?_________

71. Have you ever injured Dianetics or Scientology?_________

72. Have you ever committed any overts on a Scientology Organization?_________

73. Have you ever belonged to a group opposed to Scientology?_________

74. Have you ever stolen anything from a Scientology Organization?_________

75. Do you have any overts on LRH?_________

76. Have you done anything you wouldn’t want LRH to know about?_________

77. Do you have any overts on Mary Sue Hubbard?_________

78. Is there something Mary Sue Hubbard shouldn’t know about you?_________

79. Have you ever injured any Scientologists?_________

80. Have you ever betrayed Scientology?_________

81. Do you know of any secret plans against Scientology?_________

82. Have you ever taken money to injure Scientology?_________

83. Have you ever used Dianetics or Scientology to force sex on somebody?_________

84. Do you know of any plans to injure a Scientology Organization?_________

85. Have you done something that should never be found out?_________

86. Is there something you have avoided telling me?_________

[Questions 57 and 58 on the previous page have been corrected per HCO PL 7 April 1961RA, Revised 30 May 1975, Johannesburg Confessional List-Revised, a complete copy of which is in Volume VIII, page 419.]