[104-10193-10079.pdf — page 251]
# DECLARATION OF APPOINTEEThis form, if required, is to be completed before entrance on duty. Every question must be answered. Any false statement in this declaration will be grounds for cancellation of application or dismissal after appointment. False personation is a criminal offense and will be prosecuted accordingly.1. Present Address 247 Delaware Ave. S.W. Washington D.C.2. Who should be notified in case of emergency? C.D. Goodpasture Father3. Post Office Address: Tipton, OklahomaDoes the U. S. Government employ in a civilian capacity any relative of yours (either by blood or marriage), with whom you live or have lived, within the past 6 months? Yes or No. No If so for each such relative fill in the blanks below. If additional space is necessary, complete under Item 12.| Name | Post office address(Give street number, if any) | (1) Position and (2) Temporary or not and (3) Department or office in which employed | Relationship | Married or single | Age || ---- | ----------------------------------------------- | ------------------------------------------------------------------------------------ | ------------ | ----------------- | --- || 1.   |                                                 |                                                                                      |              |                   |     || 2.   |                                                 |                                                                                      |              |                   |     || 3.   |                                                 |                                                                                      |              |                   |     || 4.   |                                                 |                                                                                      |              |                   |     |4. Place of birth Celina, Tennessee, Clay CountyIndicate "Yes" or "No" answer by placing X in proper column|                                                                                                                                                                                                                                                                                                                                                                                                                              | Yes | No  || ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | --- | --- || 5. Are you a citizen of the United States?                                                                                                                                                                                                                                                                                                                                                                                   | X   |     || 6. If foreign born, have you furnished proof of naturalization or citizenship to (1) the U. S. Civil Service Commission?                                                                                                                                                                                                                                                                                                     |     | X   || (2) this agency in connection with this appointment?                                                                                                                                                                                                                                                                                                                                                                         |     | X   || 7. Since you filed application resulting in this appointment, has there been any change in the status of your citizenship, or of the persons through whom you gained your citizenship?                                                                                                                                                                                                                                       |     | X   || 8. (a) Do you hold any position or office under the United States or any State, Territory, County, or Municipality? If so, state the place, position, and salary under Item 12.                                                                                                                                                                                                                                              |     | X   || (b) Are you willing to resign such position or office if it becomes necessary to do so in order to hold the Federal position?                                                                                                                                                                                                                                                                                                |     | X   || 9. Do you receive any pension or other benefit for military or naval service or an annuity from the U.S. or D. C. Government under any Retirement Act? If so, give details under Item 12, stating whether you were retired for age, length of service, or disability; amount of retirement pay and under what retirement act and rank, if retired from military or naval service.                                            |     | X   || 10. Since you filed application resulting in this appointment, have you been discharged for misconduct of unsatisfactory services or forced to resign from any position? If so give under Item 12 where employed, name and address of employer and the reason for discharge in such case                                                                                                                                     |     | X   || 11. Since you filed application resulting in this appointment, have you been arrested or summoned into any civil or military court as a defendant, or indicted for or convicted of any offense (felony or misdemeanor)? If so, for each case give under Item 12 (1) the date, (2) the name and location of the court, (3) the nature of the offense or violation, and (4) the penalty, if any, imposed or other disposition. |     | X   |12. Space for detailed answers to other questionsINSTRUCTIONS TO APPOINTING OFFICERThe appointing officer before whom the foregoing certificate is made shall determine to his own satisfaction that this appointment would be in conformance with the Civil Service Act applicable civil service rules, the War Service Regulations, and acts of Congress pertaining to appointment.This form should be checked for holding of office, pension, purchase of office, suitability in connection with any record of misconduct discharge or arrest, promise to observe provisions regarding political activity, and particularly for the following:(1) Identity of appointee with the applicant whose appointment was authorized. The appointee's signature and handwriting are to be compared with the application and or other pertinent papers. The physical appearance may be checked against the medical certificate. The appointee may also be questioned on his personal history for agreement with his previous statements.(2) Age. If discrepancy exists between the date of birth and that on application, and if definite age limits have been established for the position it should be determined that applicant is not outside the age range for appointment.(3) Citizenship. The responsibility for citizenship provisions of appropriation acts prohibiting or restricting the employment remains lies with the appointingofficer. The Civil Service Commission indicates on applications showing foreign citizenship has been verified. The appointing officer should verify citizenship if the birth certificate or the letter of authority from the Commission accompanies the appointment or sufficient proof of citizenship if the application shows birth but does not indicate on its face that citizenship has been proved. If the answer to question 6 of this form shows foreign birth and the application claims birth in the United States, the case should be referred to the Civil Service Commission.(4) Members of Family. — Section 9 of the Civil Service Act provides that when- ever there are already two or more members of the family in the classified service, no other member of such family is eligible for appointment in that service. Minors who maintain a different family, merely by living at an address different from that of the parents. Doubtful cases involving more than two members of family, and all partnership cases should be referred to the Civil Service Com- mission for its duly authorized recommendations for decision. Under War Service Regulations, the member- ship provision does not apply to temporary appointments.