[104-10193-10079.pdf — page 264]
## 25. REFERENCES - List three persons living in the United States or Territories of the United States who are NOT related to you and who definitely know by knowledge of your qualifications and fitness for the position for which you are applying. Do not repeat names of supervisors listed on other items.| FULL NAME       | BUSINESS OR HOME ADDRESS (Give complete address, including street and number.) | BUSINESS OF OCCUPATION || --------------- | ------------------------------------------------------------------------------ | ---------------------- || H.B. Smith      | 2450 E. Street, N.E. D.C.                                                      | US GOVT                || Edward Saunders | Same                                                                           | US GOVT                || Mrs. D. Johnson | Same                                                                           | US GOVT                |26. May inquiry be made of your present employer regarding your character, qualifications, etc.?  ☐ Yes  ☐ NoIndicate "Yes" or "No" answer by placing X in proper column. Indicate "Yes" or "No" answer by placing X in proper column.|                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              | YES | NO  |                                                                                                                                                                                                                                                                                                                                                                                                                                                             | YES | NO  || ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | --- | --- | ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | --- | --- || 23. Are you a citizen of the United States?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  |     | X   | 35. Have you any physical defect or disability whatever? If your answer is "Yes" give complete details in Item 35.                                                                                                                                                                                                                                                                                                                                          |     | X   || 28. Do you advocate or have you ever advocated or are you now or have you ever been a member of any organization that advocates the overthrow of the Government of the United States by force or violence? If your answer is "Yes," give complete details in Item 38.                                                                                                                                                                                                                                                                                                        |     | X   | 36. (a) Were you ever in the United States Military or Naval Service during time of war? If your answer is "Yes" give complete details in Item 36.                                                                                                                                                                                                                                                                                                          | X   |     || 27. Within the past 12 months, have you habitually used intoxicating beverages to excess?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    |     | X   | (b) Is the word "honorable" or the word "satisfactory" used in your discharge or separation papers to show the type of your discharge or separation?                                                                                                                                                                                                                                                                                                        |     |     || 28. Since your 16th birthday, have you ever been convicted of or placed on probation or have ever been ordered to deposit bail after the commission of any law, police regulation or ordinance (including minor traffic violations for which a fine of $25 or less was imposed)? If your answer is "Yes" list all such cases under Item 33 below. Give in each case (1) the date, (2) the name of the city or town, (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. |     | X   | (c) Was service performed on an active full time basis with full military pay and allowances?                                                                                                                                                                                                                                                                                                                                                               |     |     || 29. Have you ever been discharged or forced to resign for misconduct or unsatisfactory service from any position? If your answer is "Yes," give in Item 30 the name and address of employer, date, and reason in each case.                                                                                                                                                                                                                                                                                                                                                  |     | X   | (d) Date of entry or entries into service Date of separation or separations. Branch of service (Army, Navy, M. C., C. G., etc.) Serial No. (If none, give grade or rating at time of separation).                                                                                                                                                                                                                                                           |     |     || 30. Do you receive an annuity from the U. S. or D. C. Government under any retirement act or any pension or other compensation for military or naval service? If your answer is "Yes," give in Item 30 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, are i ruling it retired from military or naval service.                                                                                                               |     | X   | IF YOUR ANSWERS TO THIS QUESTION (No. 36) INDICATE THAT YOU ARE ENTITLED TO VETERAN PREFERENCE, PREFERENCE WILL BE CREDITED IN THE EXAMINATION. IF APPOINTED, YOU WILL BE REQUIRED TO FURNISH TO THE APPOINTING OFFICE PRIOR TO ENTRY ON DUTY OFFICIAL EVIDENCE OF SEPARATION FROM YOUR LATEST PERIOD OF ACTIVE SERVICE IN THE ARMED FORCES OF THE UNITED STATES DURING TIME OF WAR - DO NOT SUBMIT PROOF OF DISCHARGE OR SEPARATION WITH THIS APPLICATION. |     |     || 31. Are you an official or employee of any State, Territory, county or municipality? If your answer is "Yes" give details in Item 38.                                                                                                                                                                                                                                                                                                                                                                                                                                        |     | X   | Indicate "Yes" or "No" answer by placing X in proper column                                                                                                                                                                                                                                                                                                                                                                                                 | YES | NO  || 32. Does the U. S. Government employ in a civilian capacity any relative of yours (by blood or marriage) with whom you live or have lived within the past 6 months? If your answer is "Yes," show in Item 34 for EACH such relative: (1) full name, (2) permanent address, (3) relationship, (4) department or agency by whom employed and (5) kind of appointment                                                                                                                                                                                                           |     | X   | 37. (a) If you served in the U. S. Military or Naval Service during wartime ONLY, did you participate in campaign or expedition and receive a campaign badge or service ribbon?                                                                                                                                                                                                                                                                             |     |     || 33. Have you ever had a nervous break down? If your answer is "Yes," give complete details in Item 33.                                                                                                                                                                                                                                                                                                                                                                                                                                                                       | X   |     | (b) Are you a disabled veteran?                                                                                                                                                                                                                                                                                                                                                                                                                             |     |     || 34. Have you ever had tuberculosis? If your answer is "Yes," give complete details in Item 34                                                                                                                                                                                                                                                                                                                                                                                                                                                                                |     | X   | (c) Are you the unmarried widow of a veteran?                                                                                                                                                                                                                                                                                                                                                                                                               |     |     ||                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              |     |     | (d) Are you the wife of a veteran who has service connected disability?                                                                                                                                                                                                                                                                                                                                                                                     |     |     |35. Space for detailed answers to other questions (in dicats the number to which answers applies):ITEM No.:IF YOUR ANSWER TO QUESTION 37 (a), (b) OR (c) IS "YES" AND YOU WISH TO CLAIM VETERAN PREFERENCE, ATTACH TO THIS APPLICATION VETERAN PREFERENCE CLAIM SERVICE COMMISSION FORM 14 TOGETHER WITH THE NECESSARY PROOF SPECIFIED THEREIN.THIS SPACE FOR USE OF APPOINTING OFFICE ONLYThe information contained in the answers to Question 26 above has been verified by comparison with the discharge certificate on .........................., 19.....If more space is required use paper the same size as this page. Write on each sheet your name, address, date of birth, and examination title. Attach to inside of this application.A FALSE STATEMENT ON THIS APPLICATION IS PUNISHABLE BY LAW (U. S. CODE TITLE 18 SECTION 1001).I certify that the statements made by me in this application are true, complete, and correct to the best of my knowledge and belief, and are made in good faith.Date: ..................... Signature of applicant .................................................................... (Sign your name in full, Use given name in full. If female, prefix Miss or Mrs. (Do not abbreviate). If married use your own given name.)GPO 16-47708-2