[104-10194-10023.pdf — page 78]
# 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. FRESENT ADDRESS (street and number, city and Statu)2. (A) DATE OF BIATH (P) PLACE OF BIRTH (vity of town and State or country)3. (A) IN CASE OF EMERGENCY PLEASE NOTIFY (B) RELATIONSHIP (C) STREET AND NUMBER CITY AND STATE (2) TELEPHONE M.E.H.HUNT Fathe 30 willett so. 3-6218allanybe. NA4. DOY'S THE UNITED STATES GOVERNMENT EMPLOY, IN A CIVILIAN CAPACITY, ANY RELATIVE OF YOURS (CLTHER BY BLOOD OR MARRIAGE) WITH BHON YOU LIVE OR HAVE LIVED WITHIN THE PAST IN MONTHSI YES NOIf so, for each such relative hill in the blanks below. It additional space is necessary, comriete under Item 10.| NAME | POST OFFICE ADDRESS (Give streat nuniber, if any) | (1)) TEMMARY OR T DEPARTMENT OR AGENCY IN WHICH EMPLOYIO | RELATIONSHIP | MAR- AICO Check onol | SINGLE || ---- | ------------------------------------------------- | -------------------------------------------------------- | ------------ | -------------------- | ------ ||      |                                                   |                                                          |              |                      |        ||      |                                                   |                                                          |              |                      |        ||      |                                                   |                                                          |              |                      |        ||      |                                                   |                                                          |              |                      |        ||      |                                                   |                                                          |              |                      |        ||      |                                                   |                                                          |              |                      |        ||      |                                                   |                                                          |              |                      |        |INDICATE "YES" OR "NO" ANSWER BY PLACING "X" IN PROFER COLUMN YES NO 10. SPACE FOR DETAILED ANSWERS TO OTHER QUESTIONS ITEM NO. WTUTE IN LEFT COLUMN NUMBERS OF ITEMS TO WHICH DETAILED ANSWERS APPLY5. ARE YOU A CITIZEN OF OR DO YOU OWE ALLE FIANCE ΤΟ ΤΗΣ UNITED STATESI..6. ARE YOU AN OFFICIAL OR EMPLOYEE OF ANY STATE, TERRITORY, COUNTY, OR MUNICIPALIT.....If your answer is "Yes", dive details in Item 10.7. DO YOU RECEIVE ANY ANNUSLY FHOTE THE L'NITED STATES OR DISTRICT OF COLUMBIA COVERAMENT UNDER ANY RETIHMENT ACTOR ANY FLNSION OR THE COMPENSATION FOR MILITARY OR NAVAL SERVICE?..!! your answer in "Yes", dire in trous 10 reason for retirement, that is, ade, optional disability, or by reason of voluntary ve involuntary separation after 5 years' service; amount d zetirement pay, end under what retirement act; and rating. of retired from inilitary or naval service.8. SINCE YOU FILED APPLICATION RESA TING IN TIDS APRCINTUENT HAVE YOU ELEN DISCHARGEO. OR FORCES TO R. SIGN. FOR MISCONDUCT OR UNSATIS FACTORY SERVICE FROM ANY PUSITANT......If your answer is "Yes", dire in Item 10 the name and address of employer, date and reason in each ca৪০.9. NAVE YOU PLEN ARHISTED (NOT INCLUDING TRAFFIC VICLATIONS FOR MICH YOU WERE FINED OR LESS. OR FORFTITED COLLATERAL OF $25 OR LES: SINCE YOU FILEU APPLICATION RESULTING IN THIS APPOINTMENTIIf your answer is "Yes", liat all such cases under Item 10. Give in em casa: (1) The date: (1) the nature of the offense or viclation: (.') the name and location of the court: (4) the penalty :mposed, if any, or other domestica of the cand. It appointed, your hagerprints will be taken.|     |     || --- | --- ||     |     ||     |     ||     |     ||     |     ||     |     ||     |     ||     |     ||     |     |INSTRUCTIONS TO APPOINTING OFFICERThe appointing mificer before whom the foregoing certificate is mate shall determine to his own satisfaction that this appaatment would be in confumence with the Civil Service Act, appicable Civil service Rules and Regulations ark! Lect Congress pertaining to appontinent,Ta's form should be chekel hing of office, pension, suitability in con. pection with any record of recent dinharge of artet, and particularly for the following:(1; Identity of appcintes. It is the duty of the appearing officce to guard against inpersonation and to determine beyoul reumable doubt that the is thr Bame petancitmen: was auct. The amganture and handwrong are to te coenporn! with the apricotica and other pertament papers, if the appense quined in a brities exaLI nt the signature on this form de compared with the senature on the declaration sheet, which was signed in the exution, His phas al wane may be checked against the metal corshiate. The ce mains be questioned ca als personal histray for gestaent with his revars Dosl(1) Age-if definite age limits have been established for the putitton, It should be determined that appbcant is not cutoute the age ronde for appointment, Untu such determinat male, the appointment tony not be conaminated(3) Crizons ip-The acpanting oficer is responsable for of serving the citizenship presset) the Civil Service Pules and (1) apprentiation eats Fool amtitures sa amit for both puss diserable proof of citizenship status in the abience of conting contence, lu doubtful cases the NANAient alwald not bee roummared untii siewume has been secured toga the certifying orice in the Cir: Nence Comman(4) Members of Firmy Section 9 of the Civil Service Act provides that whearser there are ready two or neve members of a tamil waving nice pretativasl or perment in the coative artsue, wher me.nter of suh family in eing the tor probaticnal e permanent app intment in the pe The appcentrarats persons cuttled to reteren preferences to the meat. The members my prec irene mensDumars may be refirio2 pare ure of the C