[104-10194-10026.pdf — page 251]
# 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)4831 SAUSPORN FORT2. (A) DATE OF BIRTH (B) PLACE OF BIRTH (city or town and State of country)OCTOBER 31, 1922 FORT WORTH TEXAS3. (A) IN CASE OF EMERGENCY PLEASE NOTIFY (B) RELATIONSHIP (C) STREET AND NUMBER, CITY AND STATE (D) TELEPHONE NO.HELEN STEVEN, WIFE 4831 SAUSPORN FORT WORTH, TEXAS4. DOES THE UNITED STATES GOVERNMENT EMPLOY, IN A CIVILIAN CAPACITY, ANY RELATIVE OF YOURS (LITHER BY BLOOD OR MARRIAGE) WITH WHOM YOU LIVE OR HAVE LIVED WITHIN THE PAST IN 12 MONTHS? YES [ ] NO [x]If so, for each such relative fill 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 EMPLOYED | RELATIONSHIP | MARRIED SINGLE (Check one) || ---- | ------------------------------------------------ | ---------------------------------------------------------------------------- | ------------ | -------------------------- || 1.   |                                                  |                                                                              |              |                            || 2.   |                                                  |                                                                              |              |                            || 3.   |                                                  |                                                                              |              |                            || 1.   |                                                  |                                                                              |              |                            || 2.   |                                                  |                                                                              |              |                            || 3.   |                                                  |                                                                              |              |                            |INDICATE "YES" OR "NO" ANSWER BY PLACING "X" IN PROPER COLUMN|                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       | YES | NO  | ITEM NO | 10. SPACE FOR DETAILED ANSWERS TO OTHER QUESTIONS WRITE IN LEFT COLUMN NUMBERS OF ITEMS TO WHICH DETAILED ANSWERS APPLY || ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | --- | --- | ------- | ----------------------------------------------------------------------------------------------------------------------- || 5. ARE YOU A CITIZEN OF OR DO 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", give details in Items 10.                                                                                                                                                                                                                                                                                                                                                        |     | X   |         |                                                                                                                         || 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?..... If your answer is "Yes", give in Item 10 reason for retirement, that is, age, optional disability, or br reason of voluntary or involuntary separation after 5 years' service, amount of retirement pay, and under what retirement act; and rating, if retired from military or naval service               |     | X   |         |                                                                                                                         || 8. SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT HAVE YOU BEEN DISCHARGED OR FORCED TO RESIGN, FOR MISCONDUCT OR UNSATIS- FACTORY SERVICE FROM ANY POSITION?... If your answer is "Yes", five in Item 10 the name and address of employer, date and reason in each case                                                                                                                                                                                                                   | X   |     |         |                                                                                                                         || 9. HAVE YOU BEEN ARRESTED (NOT INCLUDING TRAFFIC VIOLATIONS FOR WHICH YOU WERE FINED $25 OR LESS OR FORFEITED COLLATERAL OF $25 OR LESS) SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT?.. If your answer is "Yes", list all such cases under Item 10 Give in each case. (1) The date, (2) the nature of the offense of violation, (3) the name and location of the court, (4) the penalty imposed, if any, or other disposition of the case If appointed, your fingerprints will be taken | X   |     |         |                                                                                                                         |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 and Regulations and acts of Congress pertaining to appointment.This form should be consulted for holding of office, pension, suitability in competition with any record of recent discharge or arrest, and particularly for the following:(1) Identity of appointee-It is the duty of the appointing officer to guard against impersonation 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 pertinent papers. If the appointee qualified in a written exami- nation, the signature on this form should be compared with the signature on the declaration sheet, which was signed in the examination room. His physical appearance may be compared against the medical certificate. The appointee 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 t applicant 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) appropriate acts. Form 61 constitutes an affidavit for both purposes and is acceptable proof of citizenship status in the absence of conflicting circumstance. In such case the appointment should not be consummated until clearance has been secured from the certifying office of the Civil Service Commission.(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 competitive service, no other member of such family is eligible for probational or permanent appointment in the competitive service. The appointments of persons entitled to veterans preference are are 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 decision.