[104-10194-10023.pdf — page 15]
# DECLARATION OF APPOINTEEThis form is required to be completed before entrance on duty. Every question must be answered. False statements in this declaration will be grounds for refusal of appointment or dismissal after appointment. False personation is a criminal offense and will be prosecuted accordingly.1. Present Address:   50 Willut Street2. Where should be notified in case of emergency?   Street and Number:   City and State:   Telephone:   Relationship:   Willut Street   Willut H.J.   3-62183. If Government employee, are father by blood or marriage with whom you live or have lived within the past 6 months, and 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 place in which employed | Relationship | Age | Married or single || ---- | ------------------------------------------------ | ------------------------------------------------------------------------------------ | ------------ | --- | ----------------- ||      |                                                  |                                                                                      |              |     |                   ||      |                                                  |                                                                                      |              |     |                   ||      |                                                  |                                                                                      |              |     |                   ||      |                                                  |                                                                                      |              |     |                   ||      |                                                  |                                                                                      |              |     |                   |4. Place of birth:   (Town)5. Are you a citizen of the United States?6. If foreign born, have you furnished proof of naturalization or citizenship to the U. S. Civil Service Commission?7. Is any relative by blood or marriage in this appointment?8. Have you filed application claiming preference under the United States or any State Service Commission?9. Do you hold any pension or other benefit for military or naval service under the United States?10. Do you hold a commission or office under the United States or any State, Territory, County, or Municipality?11. Is this permanent position or office if it becomes vacant, likely to be filled under the provisions of the Civil Service Act?Yes No(State or Country)12. Space for detailed answers to other questions.ITEMNOWrite in left column numbers of items to which detailed answers apply13. What change in the status of your relationship of employment resulted in your appointment?14. Is the work arduous and/or dangerous?15. Have you ever pleaded guilty or been convicted of any offense against the laws?16. State under Item 12 (1) the date (2) the nature of the charge or modern charge, and (3) the nature of the disposition made of the charge or modern charge.## INSTRUCTIONS TO APPOINTING OFFICER1. State here why the appointment is necessary.2. Name those whom the foregoing constitute his or her family.3. The Civil Service Commission may require further information or evidence, such as proof of naturalization or citizenship, or other data. Under Item 12 answer fully all requests made by the Commission. If the applicant shows foreign birth attach proof.4. Members of Family - Same as 25. State the basis of authority then the appointment is made.6. The Civil Service Commission on an employee shows foreign birth that the applicant should be returned to the Civil Service. The appointing officer will secure the authority then the appointment is made.7. Forms A.8. Where are those whom the foregoing constitute his or her family?