[104-10193-10069.pdf — page 87]
# 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   6300 St. Charles Avenue, New Orleans 15 La.2. Who should be notified in case of emergency?   Mrs. W. P. Burke wife   6300 St. Charles Ave New Orleans La3. Does the U.S. Government employ in a civilian capacity any relative of yours (father 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. (Information is necessary complete under Item 12.)| Name | Postoffice address (Give street number, if any) | Bureau or Territory or inst. Branch or Department or office in which employed | Relationship | Married or single | Age || ---- | ----------------------------------------------- | ----------------------------------------------------------------------------- | ------------ | ----------------- | --- || 1.   |                                                 |                                                                               |              |                   |     || 2.   |                                                 |                                                                               |              |                   |     || 3.   |                                                 |                                                                               |              |                   |     || 1.   |                                                 |                                                                               |              |                   |     || 2.   |                                                 |                                                                               |              |                   |     || 3.   |                                                 |                                                                               |              |                   |     || 1.   |                                                 |                                                                               |              |                   |     || 2.   |                                                 |                                                                               |              |                   |     || 3.   |                                                 |                                                                               |              |                   |     |4. Place of birth   New Orleans LaIndicate "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 in 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 or unsatisfactory service, 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 each 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 questions.| ITEM NO. | Write in left column numbers of items to which detailed answers apply || -------- | --------------------------------------------------------------------- || 8        | U.S. Marine Corps Reserve. Inactive duty status.                      |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, 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 desertion 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 with the medical certificate. The appointee may also be questioned on his personal history for agreement with his statements.(2) Age. If the discrepancy exists between the date of birth and that on application and if definite, is in any event excessive for the position, it should be determined that applicant is not outside the age range for appointment.(3) Citizenship. The responsibility for observing the provisions of appropriation acts prohibiting or restricting the employment of aliens rests with the appointing officer. The Civil Service Commission indicates on applications showing foreign birth whether citizenship has been verified. The appointing officer should verify citizenship at the list of eligibles or the letter of authority from the Commission, unless the requirement is waived by proof of citizenship, or if the applicant has presented an application on its face that citizenship has been proved. If the answer to question 4 of this form shows foreign birth and the application indicates residence 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 where there are 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 do not establish a different family merely by living at an address different from that of the parents. Doubtful cases involving more than two members of family, or indicating an apparent misrepresentation, should be referred to the Civil Service Commission with all information presentatives for decision. Under War Service Regulations the one member of family provision does not apply to temporary appointments for one year or less.4 PRINTING OFFICE 16-52354-1