[104-10194-10019.pdf — page 163]
# DECLARATION OF APPOINTEEThis form is to be completed before entrance on duty. Question 3 is to de answered in all cases, otherwise answer only those questions which require an answer different from that given to the corresponding questions on your application form. If no answers are different, wie "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)3601. Odt Bridensburg Rd. Silver Spring Md.2. (A) DATE OF BIRTH (B) PLACE OF BIRTH (city or town and State or country)20 Jan 1924 Baltimore Md.3. (A) IN CASE OF EMERGENCY PLEASE NOTIFY (B) RELATIONSHIP (C) STREET AND NUMBER CITY AND STATE (D) TELEPHONE NO.HARRIETTE D. RICHARDSON WIFE 3001 Old-ss-Md SL-39534. 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 WITHIN THE PAST 24 MONTHS? YES NOIf an, for each auch relative nil in the blanke below. If additional space is necessary, comatase andbe item 10.| NAME | POST OFFICE ANDRESS (Give stroot number, if any) | POSITION (2 TEMPORARY OR NOT 3 AGENCY IN WHICH SWPLOYED | RELATION SHIP | MARRIED SINGLE (Check one) || ---- | ------------------------------------------------ | ------------------------------------------------------- | ------------- | -------------------------- ||      |                                                  |                                                         |               |                            ||      |                                                  |                                                         |               |                            ||      |                                                  |                                                         |               |                            ||      |                                                  |                                                         |               |                            ||      |                                                  |                                                         |               |                            |INDICATE "YES" OR "NO" ANSWER BY PLACING "X" IN PROPER COLUMN|                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    | YES | NO  || ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ | --- | --- || 5. ARE VOLI A CITIZEN OF YOU OWE ALLEGIANCE TO THE UNITED STATES..                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 | X   |     || 6. ARE YOU AN OFFICIAL OR EMPLOYEE OF ANY STATE, TERRITORY, COUNTY, OR MUNICIPALITY!... If your answer is "Yes", dive detaila in Item 10.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          |     | X   || 7. DO YOU RECEIVE ANY ANNLITY FROM THE UNITED STATES OR DISTRICT OF COLUMBIA GOVERNMENT UNDER ANY RETIREMENT ACT OR ANY PENSION OR OTHER COMPENSATION FOR MILITARY OR NAVAL SERVICE?...... If your answer is "Yes", dive in Item 10 reason for retirement, that is, age, optional disability, or hy reason of voluntary or involuntary separaton after 5 years' service; amount of retirement pay, and under what retirement act; and rating, if retired from military or naval service.                                                                                                                                                                                                                           |     | X   || 8. HAVE YOU EVER BEEN DISCHARGED, OR FORCED TO RESIGN, FOR MISCONDUCT OR UNSATISFACTORY SE HVICE FROM ANY POSITION?..... H your answer is "Yes", give in Item 10 the name and address of employer, date, and reason in each case.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  |     | X   || 9. SINCE YOUR 16TH BIRTHDAY, HAVE YOU EVER BEEN ARRESTED, INDICTED, OR SUMMONED INTO COURT AS A ULFENDANT IN A CRIMINAL PROCEEDING, OR CONVICTED, FINED, OR IMPRISONED, OR PLACE DON PROBATION, OR HAVE YOU EVER BEEN ORDERED TO CLAUSIT BAIL OR COLLATERAL FOR THE VIOLATION OF ANY LAW, POLICE REGULATION, OROROWANCE (EXCLUDING MINOR TRAFFIC VIOLATIONS FOR WHICH A FINE OR FORFLITRE OF SOR LESS WASINPOSED) If your answer is "Yes", list all such cases under Item 10. Give in each case: (1) The date: (1) the nature of the offense or violation; (3) the name and keation of the court: (4) tho penalty imposed, if any, or other disposition of the case. It appointed, your Angerprints will be taken. |     | X   |10. SPACE FOR DETAILED ANSWERS TO OTHER QUESTIONSWRITE IN LEFT COLA TABERS OF ITEMS TO WHICH DETAILED ANSWERS APPLYINSTRUCTIONS TO APPOINTING OFFICERThe appointing officer before whom the foregoing cerficate is made shall determine to his own satisfaction that this appointment would be in conformance with the Civil Servire Act, appientle Civil Service Rules and Regulations and acts of Congress pertaining to appuntment.This form should be checked for holding of office, pension, suitability in ca nection with any record of recent discharge of 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 ;ertinent papers. The physical appearance may be checked against the medical certificate. The appoihtre 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 appointmeat, Until auch determination is rande, the appointment may not be masummate(3) Citizenship-The appointing officer is responsible for observing the citizenship was the Civil Service Rules and (1) appropпatica ats Form bi costures weiduvet for both purposes and is avversarie peer of citizenship status in the chance of conflicting evidence. In doubtful cases the tsaldevanymmated until clearance has been secured tom the certifying of the Oved Service Cominussion,(4) Members Famil-Section 9 of the Civil Service Act provides thet whenever there are my two or more members of a family serving noder probational or permenore aparatment in the competitive servwe, na weber member of such famibie for probational or permanent appuntment in the comretine serve. De appointments of pernas zum veteran preferene are ייל זילבאיםuirement. The members-of-fami's pro es not to try atments, Doubtful cases may be referred to the appropriate beste Ovil Service Commission for devision.