[104-10194-10019.pdf — page 167]
# DECLARATION OF APPOINTEEThis form is to be completed before entrance on duty. Question 3 is to be answered in all cases, otherwise answer only those questions which require an answer diferent from that given to the corresponding questions on your application feem. If no answers are dicessat, write "NONE" in Item 10, below. Any false statement in this declaration will be grounds for cancellation of application or dismissal atter appointment. Impersonation is a criminal offense and will be prosecuted accordingly.1. PRESENT AOGRESS (streer and auniber, city and Stace)2(A) DATE OF BIRTH (B) PLC OF BIRTH (city or town and Stare or country)3. (A) IN CASE OF EMERGENCY PLEASE NOTIFY (8) RELATIONSHIP (C) STREET ΑΠΟ ΜΟNSER CITY AND STATE (D) TELEPHONE MOHARRIETNE D. WIFE 722 LOYAL ST.,.ALEXANOKIA, A. TE 8506& DOES THE UNITED STATES COVER WENT EMPLOY, IN A CULIAR CAPACITY, ANY RELATIVE OF YOURS CEPTHER BY BLOOD OR MARRIAGE) WITH WHOM YOU LIVE OR HAVE LIVED WITHTHE PAST 24 MONTHS YES NOIf so, for each such relative all in the blanks bedre If additional space is necessary, complete under Item 10.NAME POST OFFICE ADDRESS ANTICA (1) TEMACRARY OR NOT RELATION- SINGLE(Gore street number, if any) DEPARTMENT OR AGENCY IN WHICH SHIP (Check one)EMPLOYEDINDICATE "YES" OR "NO" ANSWER BY PLACING "X" IN PROPER COLUMNS. ARE YOU A CITIZEN OF OR DO YOU CWE ALLEGIANCE TO THE UMTS STATES YES NO 10. SPACE FOR DETAILED ANSWERS TO OTHER QUESTIONS& ARE YOU AN OFFICIAL OR EMPLOYEE OF ANY STATE, TERRITORY, COUNTY, OR ITEM WRITE EN LEFT COLUMN IPIMBERS OF ITEMS TO WHICH DETAILED ANSWERS APPLYMUNICIPALIM........ NO. NINEIf your answer is "Yos", give details in Item 10.7. DO YOU RECEIVE ANY ANNLITY FROM THE UNITED STATES OR DISTRICT OF   COLUMBIA GOVERNMENT UNDER ANY RETIREMENT ACT OR ANE FRINGION OR   OTHER COMPENSATION FOR MILITARY OR NAVAL SERVICET.If your answer is "Yes", fire in Item 10 reason for recicecment,that is, age, optional disability, or by reason of voluntaryor involuntary separation after 3 years' service; amount ofretirement pay, and under what retirement act; ant ratingif retired from military on Garal service.& HAVE YOU EVER BEEN DISCHARGED OR FORCED TO RESIGN, FOR MISCONDUCTOR UNSATISFACTORY SERVICE FROM ANY POSITION?..If your answer is "Yes", we in item 10 the name and addressof employer, date, and ressan in each case.9. SINCE YOUR 16TH BIRTHDAY, HAVE YOU EVER BEEN ARRESTED ITACICTED, OR   SUMMONED INTO COURT AS A DEFENDANT IN A CRIMINAL PROSECING, OR   CONVICTEO, FINED, OR IMPRISONED OM PLACED ON PROBATICS HAVE VO   EVER BEEN ORDERED TO DEPOSIT BALL OR COLLATERAL FOR THE CLATION   OF ANY LAW, POLICE REGULATAWYRONANCE (EXCLUDING RINER TRAFFIC   VIOLATIONS FOR WHICH A FINE OR FORFED TURE OF $25 OR LESS WAS MEUSEDJIf your answer is "Yes", lis: all such cases under Izam 10.Give in ench case: (1) The dare: (2) the nature of the cdenseor violation; (3) the name and location of the court (4) thepenalty imposed, if any, or other disposition d'the case.Il appointed, your fingerpieta will be taken..INSTRUCTIONS TO APPOINTING OFFICERThe-appointing officer before whom the foregoing erotieste is made shalldetermine to his own satisfaction that this appointment woud Le in conformancewith the Civil Service Act, ppable Civil Service Rula and Regulations andacts of Congress pertaining to apecinment,This form should be checked for boiding of office, pension, suitability in con-nection with any record of recent discharge of arrest, and particularly for thefollowing:(1) Identity of appointes. The appointee's signature and handwriting areto be compared with the appletion and or other pertinent pepers. Thephysical appearance may be checked against the medical certifieste, Theappointee may also be questioned on his personal history in agreement with hisprevious statements.(2) Age-If definite age limita Lave been established in the position, it shouldbe determined that applicant is set outside the age range for appointment.Until such determination is made, tae appointment may it be consummated(3) Citizenship The appointing officer is responsible for observing thecitizenship pronsons of (1) the Ciril Service Rules and (2) appropriation acts.Form 61 crescitutes an affidavit for both purposes and is acceptahie proof ofcitimaskip the absence of conflicting evidence. In doubtful case's theappointmes: have be consummated until clearance has been secured fromthe certifying office of the Civil Comunission,(4) Members of Family-Section 9 of the Civil Service Act provides thatwhenever there are s'realy two or more members of a family serving underprobational or permanent appointment in the competitive service, no othermember of such family is eligible for probational or permanent appointment inthe wepesort The appointments of persons entitled to veterapreference are not subject to this requirement. The members-of-family provisiondoes לו אב op temporary appuntments. Doubtful cases may be referred tothe appropriate offer of the Civil Service Commission for decision.