[104-10194-10014.pdf — page 191]
# DECLARATION OF APPOINTEEThis form is to be completed before entrance on duty. Answer all questions. 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)3212 SOUTH 9 ST. ARLINGTON, VIRGINIA2. (A) DATE OF BIRTH (B) PLACE OF BIRTH (city or town and State or country)FEB 19. 1917 ELMHURST NEW YORK3. (A) IN CASE OF EMERGENCY PLEASE NOTIFY (B) RELATIONSHIP (C) STREET AND NUMBER, CITY AND STATE (2) TELEPHONE NO.VIRGINIA P. CONNEL WIFE 3212 ARHINGTON VIRGINIA 12-36224. DOES THE UNITED STATES GOVERNMENT EMPLOY, IN A CIVILIAN CAPACITY, ANY RELATIVE OF YOURS (EITHER BY BLOOD OR MARRIAGE WITH WHOM YOU LIVE OR NAVE LIVED WITHIN THE PAST 24 MONTHST YES NOIf so, for each such relative fall in the blanks below. If additional space is necessary, complete under Item 10.| NAME | POST OFFICE ADDRESS (Give street number, if any) | (1) POSITION (:) TEMPORARY OR NOT (3) DEPARTMENT OR AGENCY IN WHICH ENPLOYED | RELATIONSHIP | MAR.RIED (Check one) | SINGLE || ---- | ------------------------------------------------ | ---------------------------------------------------------------------------- | ------------ | -------------------- | ------ || 1.   |                                                  |                                                                              |              |                      |        || 2.   |                                                  |                                                                              |              |                      |        || 3.   |                                                  |                                                                              |              |                      |        || 1.   |                                                  |                                                                              |              |                      |        || 2.   |                                                  |                                                                              |              |                      |        || 3.   |                                                  |                                                                              |              |                      |        |INDICATE "YES" OR "NO" ANSWER BY PLACING "X" IN PROPER COLUMN|                                                                                                                                                                                                                                                                                                    | YES | NO  | 10. SPACE FOR DETAILED ANSWERS TO OTHER QUESTIONS                              || -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | --- | --- | ------------------------------------------------------------------------------ || 5. ARE YOU A CITIZEN OF OR DO YOU OWE ALLEGIANCE TO THE UNITED STATEST                                                                                                                                                                                                                             | X   |     | ITEM NO. WRITE IN LEFT COLUMN NUMBERS OF ITEMS TO WHICH DETAILED ANSWERS APPLY || 6. APE YOU AN OFFICIAL OR EMPLOYEE OF ANY STATE, TERRITORY. COUNTY, OR MUNICIPALITY?.....                                                                                                                                                                                                          |     | X   |                                                                                || If your answer.is "Yes", give details in Item 10.                                                                                                                                                                                                                                                  |     |     |                                                                                || 7. DO YOU RECEIVE ANY ANNUITY FROM THE UNITED STATES OR DISTRICT OF COLUMBIA GOVERNMENT UNDER ANY RETIREMENT ACT OR ANY PENSION OR OTHER COMPENSATION FOR MILITARY OR NAVAL SERVICE?......                                                                                                         | X   |     |                                                                                || If your answer is "Yes", give in Item 10 reason for retirement. that is, ege, optional disability, or by reason of voluntary of involuntary separation after 5 years' service; amount of retirement pay, and under what retirement act; and rating it retired from military or naval service.      |     |     |                                                                                || 8. SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT HAVE YOU BEEN DISCHARGED, OR FORCED TO RESIGN, FOR MISCONDUCT OR UNSATISFACTORY SERVICE FROM ANY POSITION?...                                                                                                                         | X   |     |                                                                                || If your answer ig"Yes", give in Item 10 the name and address of employer, date and reason in each case.                                                                                                                                                                                            |     |     |                                                                                || 9. HAVE YOU BEEN ARRESTED (NOT INCLUDING TRAFFIC VIOLATIONS FOR WHICH YOU WERE FINED $25 OR LESS, OR FORFEITED COLLATERAL OF 125 08 LESS, SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT                                                                                                | X   |     |                                                                                || It your answer is "You", list aid such cases under Item 10. Give in each case: (1) The date; (2) the nature of the offense or viodation; (3) the name and location of the court: (1) the penalty imposed, if any, ce other disposition of the caso. If appointed, your fingerprints will be taken. |     |     |                                                                                |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, applicabic Civil Service Rules and Regulations and acts of Congress pertaining to appointment,This form should be chorked he holding of office, pension, suitability in connection with any record of recent discharge of arrest, and particularly for the following:(1) Identity of appointee. It is the duty of the appointing officer to guard against inpersonation and to determine beyond reasonable doubt that the appointee is the same person whose appointment was authorized. The appointee's signature and handwriting are to be compared with the application and or other pertiment papers, If the appointee qualified in a written examination, the signature on this form should be compared with the signature on the declaration sheet, which was signed in the examination roo(2) Ado.-If definite age limits have been estabhahed for the position, it should be determined that speiscant is not outside the age range for appointment. Until such determination is made, the appointment may not be consummated.(3) Citizenship-The appointing officer is responsible for observing the citizenship provisions of (1) the Civil Service Rules and (2) appropriation acts, Form 61 constitutes an affidavit for both purposes and is aceptable proof of citizenship status in the absence of contheting evntence, la doubtful cases the appointment should not be consummated until clearance has been secured from the certifying office of the Civil Service Commisson,(4) Members of Family -Section 9 of the Civil Service Act provides that whenever there are already two or more members of a family serving under probational or permanent appointment in the compentive service, no other member of such family in eligible for probational or permanent appointment in the competitive service. The appointments if perancs carried to veteran perference are the subject to this requirement. The members of family provision does not apply to temporary appointments, Doubtful cases may be referred to the appropriate office of the Civil Service Commission for devisionhis physical appearance may be checked against the medical certificate. The appointee may also be questicaed on his personal history for agreement with his previous ctatements,4.1. LOTO Rinting OFFICE 16-34190-8