[104-10193-10079.pdf — page 248]
# DECLARATION OF APPOINTEEThis form is to be completed before entrance on duty. Question 3 is to be answered in all cases, otherwise answer only those questions which require an answer different from that given to the corresponding question's on your application form. If no answers are different, write "NONE" in Item 10, below. Any false statement in this declaration will be grounds for cancellation of application or dismissal after appointment. Impersonation is a criminal offense and will be prosecuted accordingly.1. PRESENT ADDRESS (street and number, city and State)5555 CONN AVE N.W.APT. 19 WASH, D.C.2. (A) DATE OF BIRTH (B) PLACE OF BIRTH (city of town and State or country)Nov. 28, 1918 CELINA, TENNESSEE, U.S.A.3. (A) IN CASE OF EMERGENCY PLEASE NOTIFY (B) RELATIONSHIP (C) STREET AND NUMBER, CITY AND STATE (D) TELEPHONE NO.C.H. COWLPASTURE FATHER 752 E. MAIN ST. TIPTON, OKLA 1254. DOES THE UNITED STATES GOVERNMENT EMPLOY, IN A CIVILIAN CAPACITY, ANY RELATIVE OF YOURS (EITHER BY BLOOD OR MARRIAGE) WITH WHOM YOU LIVE OR HAVE LIVED WITHHER IN   THE PAST 24 MONTHS? YES [ ] NO [X]If additional space is necessary, complete under Item 10.| NAME | POST OFFICE ADDRESS (Give street number, if any) | (1) POSITION (2) TEMPORARY OR NOT (3) DEPARTMENT OR AGENCY IN WHICH EMPLOYED | RELATIONSHIP | MARRIED | SINGLE (Check one) || ---- | ------------------------------------------------ | ---------------------------------------------------------------------------- | ------------ | ------- | ------------------ ||      |                                                  |                                                                              |              |         |                    || 1.   |                                                  |                                                                              |              |         |                    || 2.   |                                                  |                                                                              |              |         |                    || 3.   |                                                  |                                                                              |              |         |                    || 1.   |                                                  |                                                                              |              |         |                    || 2.   |                                                  |                                                                              |              |         |                    || 3.   |                                                  |                                                                              |              |         |                    || 1.   |                                                  |                                                                              |              |         |                    || 2.   |                                                  |                                                                              |              |         |                    || 3.   |                                                  |                                                                              |              |         |                    |INDICATE "YES" OR "NO" ANSWER BY PLACING "X" IN PROPER COLUMN|                                                                                                                                                                                                                                                                                                                                                                                                                      | YES | NO  | ITEM NO. | 10. SPACE FOR DETAILED ANSWERS TO OTHER QUESTIONS WRITE IN LEFT COLUMN NUMBERS OF ITEMS TO WHICH DETAILED ANSWERS APPLY || -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | --- | --- | -------- | ----------------------------------------------------------------------------------------------------------------------- || 5. ARE YOU A CITIZEN OF OR DO YOU OWE ALLEGIANCE TO THE UNITED STATES?                                                                                                                                                                                                                                                                                                                                               | X   |     |          |                                                                                                                         || 6. ARE YOU AN OFFICIAL OR EMPLOYEE OF ANY STATE, TERRITORY, COUNTY, OR MUNICIPALITY                                                                                                                                                                                                                                                                                                                                  |     | X   |          |                                                                                                                         || If your answer is "Yes", give details in Item 10.                                                                                                                                                                                                                                                                                                                                                                    |     |     |          |                                                                                                                         || 7. DO YOU RECEIVE ANY ANNUITY FROM THE UNITED STATES OR DISTRICT OF COLUMBIA GOVERNMENT UNDER ANY RETIREMENT ACT OR ANY PENSION OR OTHER COMPENSATION FOR MILITARY OR NAVAL SERVICE?                                                                                                                                                                                                                                 |     | X   |          |                                                                                                                         || If your answer is "Yes", give in Item 10 reason for retirement, that is age, optional disability, or by reason of voluntary or involuntary separation after 5 years' service, amount of retirement pay, and under what retirement act, and rating, if retired from military or naval service.                                                                                                                        |     |     |          |                                                                                                                         || 8. HAVE YOU EVER BEEN DISCHARGED, OR FORCED TO RESIGN, FOR MISCONDUCT OR UNSATISFACTORY SERVICE FROM ANY POSITION?                                                                                                                                                                                                                                                                                                   |     | X   |          |                                                                                                                         || If your answer is "Yes", give in Item 10 the name and address of employer, date, and reason in each case.                                                                                                                                                                                                                                                                                                            |     |     |          |                                                                                                                         || 9. SINCE YOUR 18TH BIRTHDAY, HAVE YOU EVER BEEN ARRESTED, INDICTED, OR SUMMONED INTO COURT AS A DEFENDANT IN A CRIMINAL PROCEEDING, OR CONVICTED, FINED OR IMPRISONED OR PLACED ON PROBATION OR HAVE YOU EVER BEEN ORDERED TO DEPOSIT BAIL OR COLLATERAL FOR THE VIOLATION OF ANY LAW POLICE REGULATION OR ORDINANCE (EXCLUDING MINOR TRAFFIC VIOLATIONS FOR WHICH A FINE OR FORFEITURE OF $25 OR LESS WAS IMPOSED)? |     | X   |          |                                                                                                                         || If your answer is "Yes", list all such cases under Item 10. Give in each case. (1) The date (2) the nature of the offense or violation. (3) the name and location of the court. (4) the penalty imposed, if any, or other disposition of the case. If appointed your fingerprints will be taken.                                                                                                                     |     |     |          |                                                                                                                         |INSTRUCTIONS 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 and Regulations and acts of Congress pertaining to appointments.This form should be checked for holding of office, pension, suitability in connection with any record of recent discharge or arrest, and particularly for the following:(1) Identity of appointee.- 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 definite age limits have been established for the position, it should be determined that applicant is not outside the age range for appointment. Until such determination is made, the appointment may not be consummated.(3) Citizenship.-The appointing officer is responsible for observing the citizenship provisions of (1) the Civil Service Rules and (2) appropriation acts. Form 61 constitutes an affidavit for both purposes and is acceptable proof of citizenship status in the absence of written evidence. In doubtful cases the appointment should not be consummated until clearance has been secured from the certifying office of the Civil Service Commission.(4) Members of Family.-Section 9 of the Civil Service Act provides that whenever there are already two or more members of a family serving under probational or permanent appointment in the competitive service, no other member of such family is eligible for probational or permanent appointment in the competitive service. The appointments of persons entitled to veteran preference are not subject to this requirement. The members-of-family provision does not apply to temporary appointments. Doubtful cases may be referred to the appropriate office of the Civil Service Commission for decision.U. S. GOVERNMENT PRINTING OFFICE 16-65160-1