[104-10194-10023.pdf — page 207]
# DECLARATION OF APPOINTEEThis form is to be completed before entrance on duty. Answer all questions. Admitted unfavorable information about such matters as arrests or discharges will be considered together with the favorable information in your record in determining your present fitness for Federal employment. However, a false statement or dishonest answer to any question may be grounds for dismissal after appointment and is punishable by law.1-PRESENT ADDRESS (street and number, criy and State)11120 Riven Road Potomac, Md. 208542 (A) DATE OF BIRTH (R) PLACE ( BIRTH (city and State or city and foreign country)Oct. 9, 1918 Hamburg, N. Y.2 (0) IN CASE OF EMERGENCY, PLEASE NOTIFY (2) RELATIONSHIP (C) STREET AND NUMBER, CITY AND STATE (C) TELEPHONE NODorothy L. Hunt wife 11120 River Rd. Potomac Md. 299 7366• DOES THE UNITED STATES GOVERNMENT EMPLOY, IN A CIVILIAN CAPACITY, ANY RELATIVE OF YOURS (EITHER BY BLOOD OR MARRIAGE) WITH WHOM YOU LIVE ON HAVE LIVED WITHINTHE PAST 24 MONTHST YES NOIt so, for each such relative hil in the blank below If additional space is necessary, complete under Item 12| NAME | POST OFFICE ADDRESS (Give street number, if any) | POSITION TEMATRARY OR NOT (1) DEPARTMENT OM AGENCY IN WHICH EVALDIED | RELATIONSHIP | MAR. RIED (Check one) | 31 GLE || ---- | ------------------------------------------------ | -------------------------------------------------------------------- | ------------ | --------------------- | ------ || 1.   |                                                  |                                                                      |              |                       |        || 2    |                                                  |                                                                      |              |                       |        || 3.   |                                                  |                                                                      |              |                       |        || 1.   |                                                  |                                                                      |              |                       |        || 2    |                                                  |                                                                      |              |                       |        |INDICATE ANSWER BY PLACING "X" IN PROPER COLUMN YES NO INDICATE ANSWER BY PLACING "X" IN PROPER COLUMN YES NO| & (A) ARE YOU A CITIZEN OF THE UNITED STATES OF AMERICA, OR (B) AS A NATIVE OF AMERICAN SAMOA DO YOU OWE ALLEGANCE TO THE UNITED STATES OF AMIRICAP | X   |     || --------------------------------------------------------------------------------------------------------------------------------------------------- | --- | --- || & ARE YOU AN OFFICIAL OR EMPLOYEE OF ANY STATE, TERRITORY, COUNTY, OR MUNICIPALITY!                                                                 |     | X   |If your answer is "Yes," five details in Item 127. DO YOU RECEIVE OR MAVE YOU APPLIED FOR AN ANNUITY FROM THE UNITED STATES CA DISTRICT OF COLL, MBIA GOVERNMENT UNIER ANY RETIREMENT ACT OR ANY PENSION OR OTHER COMPENSATION FOR MILITARY OR NAVAL SERVICE | | X |Il your answer is "Yes," give details in Item 12| 10 (A) MAVE YOU EVER FILES & WAIVER OF LIFE INSURANCE COVERAGE UNDER THE FEDERAL EMPLOYEES GROUP LIFE INSURANCE ACTI | X   |     || -------------------------------------------------------------------------------------------------------------------- | --- | --- || (B) IF YOU HAVE FILED SUCH A WAIVER HAS IT BEEN CANCELED OR RETONEDI                                                 |     | X   |11. SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT:    Α. ΜΑΣ YOU BEEN DISCHARGEO FROM EMPLOYMENT BECAUSE.    (1)DUCT WAS NOT SATISFACTORY? | Y |    (2) YOUR WORK WAS NOT SATISFACTORY? | Y |    B. HAVE YOU RESIGNED AFTER OFFICIAL OTIFICATION THAT:    (1) YOUR CONDUCT WAS NOT SATISFACTORY? | X |    (2) YOUR WORK WAS NOT SATISFACTORY? | X |    C. HAVE YOU BEEN DISCHARGED FROM THE ARMED SERVICES LASER OTHER THAN HONORABLE CONDITIONS? | X |    8 SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT, HAVE YOU BEEN ARRESTED CHARGED OR HELD DY FEDERAL STATE, OR OTHER LAW ENRVAEMENT AUTHORITIES FOR ANY VIOLATION OF ANY FEDERAL LAW STATE LAW COUNTY OR MUNICIPAL LAW RIGULATION OR ORDINANCE DO NOT INCLUDE TRAFFIC VIOLATIONS FOR WH.CH A FINE OF 125 OR LESS WAS IMPOS ALL OTHER CHARGES MUST BE INCLUDED EVEN IF THEY WERE DISMISSED | | X |    If your answer is "Yes," give in Item 12 for each case (1) approximate date, (2) charge, (3) place, (4) action taken    9 SINCE YOU FILED APPLICATION RISULTING IN THIS APPOINTMENT, HAVE YOU BEEN BARRED BY THE U S. CIVIL SERVICE COMMISSION FROM TAKING EXAM NATIONS OR ACCEPTING CIVIL SERVICE APPOINTMENTSI | | X |    If your answer is "Yes." give dates of and reasons for such debartment in tem    If your answer to A. B. or C "You." give details in Item 12 as clearly as you can remember, including the name and address of employer, approstmate dare, and reasons in each case12 SPACE FOR DETAILED ANSWERS TO OTHER QUESTIONS (Indicate item numbers to which answers apply)| ITEM NO | ITEM NO. || ------- | -------- |INSTRUCTIONS TO APPOINTING OFFICER.-You must determine that this appointment would be in conformance with the Civil Service Act, appinubic Civil Service Rules and Regulations, and acts of Congress pertaining to appointment. This form should be checked for holding of office, pension, any record of recent discharge or arrest, age, citizenship, and mem- bers of family. Also, to establish the identity of the appointee, you should particularly check (1) his signature and handwriting against the application and; or other pertinent papers and (2) his physical appearance against the medical certificate.