[104-10194-10001.pdf — page 119]
# 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)   WESLEY HALL 426 21st STR. N.W. WASHINGTON, D.C.2 (A) DATE OF BIRTH (B) PLACE OF BIRTH (city or town and State or country)Nov. 2. 1905. EKATERINOSLAV RUSSIA3. (A) IN CASE OF EMERGENCY PLEASE NOTIFY (D) RELATIONSHIP (C) STREET AND NUMBER, CITY AND STATE (D) TELEPHONE NO.   ANNA TARASIFF WIFE 16.315 BEVIL WAY, SHYLE BR 6-0172   CALIF.& 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 28 MONTHST YES NOIf so, for each auch 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 (2) TEMPORARY OR NOT (3) DEPARTMENT OR AGENCY IN WHICH EMPLOYED | RELATION- SHIP | MAR- RICO (Check one) | SINGLE || ---- | ------------------------------------------------ | ---------------------------------------------------------------------------- | -------------- | --------------------- | ------ ||      |                                                  |                                                                              |                |                       |        ||      |                                                  |                                                                              |                |                       |        ||      |                                                  |                                                                              |                |                       |        ||      |                                                  |                                                                              |                |                       |        ||      |                                                  |                                                                              |                |                       |        ||      |                                                  |                                                                              |                |                       |        ||      |                                                  |                                                                              |                |                       |        ||      |                                                  |                                                                              |                |                       |        ||      |                                                  |                                                                              |                |                       |        |INDICATE "YES" OR "NO" ANSWER BY PLACING "X" IN PROPER COLUMN|                                                                                                                                                                                                                                                                                                   | YES | NO  || ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | --- | --- || &. ARE YOU A CITIZEN OF OR DO YOU OWE ALLEGIANCE TO THE UNITED STATES?..                                                                                                                                                                                                                          | X   |     || &. ARE YOU AN OFFICIAL OR EMPLOYEE OF ANY STATE, TERRITORY, COUNTY, OR MUNICIPALITYI...                                                                                                                                                                                                           |     | X   || Il your answer is "Yes", give details in Item 10.                                                                                                                                                                                                                                                 |     |     || 7. DO YOU RECEIVE ANY ANNUITY FROM THE UNITED STATES OR DISTRICT OF COLI MBIA GOVERNMENT UNDER ANY RETIREMENT ACT OR ANY PENSION OR OTHER COMPENSATION FOR MILITARY OR NAVAL SERVICEY                                                                                                             | X   |     || If your answer is "Yes", givo in Item 10 reason fue retisement, that is, age, optional disability, or by reason of voluntary or involuntary separation after 5 years service; anmount of retirement pay, and under what retirement act; and rating, if retired from military or naval servico.    |     |     || &. SINCE YOU FILED APPLICATION PESULTING IN THIS APPOINTMENT HAVE YOU BEEN DISCHARGED, OR FORCED TO RESIGN, FOR MISCONDUCT OR UNSATIS FACTORY SERVICE FROM ANY POSITION....                                                                                                                       |     | X   || If your answer is "Yes", givo in Item 10 the name and address of employer, date and reason in each case.                                                                                                                                                                                          |     |     || 2. HAVE YOU BEEN ARRESTED (NOT INCLUDING TRAFFIC VICLATIONS FOR WHICH YOU WERE FINED S'S OR LESS, OR FORI FITED COLLATERAL OF $75 OR LESS) SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT                                                                                              | X   |     || 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 or violation; (3) the name and heation of the court. (4) the penalty imposed, if any, or other disposition of the caso. It appointed, your fingerprints will be taken. |     |     |10. SPACE FOR DETAILED ANSWERS TO OTHER QUESTIONS| ITEM NO. | WRITE IN LEFT COLUMN NUMBERS OF ITEMS TO WHICH DETAILED ANSWERS APPLY || -------- | --------------------------------------------------------------------- || 7        | HAVE YOU ROO                                                          ||          | n                                                                     || 8.       | HAS JEATEE FACT EXPIRED?                                              ||          |                                                                       |INSTRUCTIONS TO APPOINTING OFFICERThe appointing officer before whom the foregoing certificate is male shall determine to his own satisfaction that this appointment would be in conformance With the Civil Service Act, appheatde Civil Service Rules and Regulations and ts of Congress pertaining to appointment,This form should be checked for hokling of office, pension, suitability in con- myton with any record of recrent discharge of arrest, and particularly for the following:(1) Identity of appointee-It is the duty of the appointing officer to guard against inperwonation and to determine beyond reasonable doubt that the was authorised. Thetee is the same person whose appuntment appointer's signature and handwriting are to be compared with the applicatio antee other pertinent papers. If the apscantee qualibed in a written exami- Baton, the sugnature on this farm should be compared with the signature on the declaration sheet, which was gned in the examinata mm. Ha physend appearance may be checked against the medwal certificate. The appunnice may also be questioned on his personal history for agreement with his previous statements,(1) Ade. If definite age limits have been established for the position, it shouki be determined that applicant is not outside the age range for appuntment. Until such determination is inade, the appuintment may not be consummate 1.(3) Citizenship -The appointing officer is responsable for observing the citizen.hip provisoms of (1) the Civil Service Rules and appropriation acts Form Gtatutes an athtavit fith purposes and is acce stable proof of citizenship status in the absence of conilisting evidence. In doubtful roses the oppantment should not be consummated until clearance has been secured from the certifying ofhre of the Civil Servre Comnusm(4) Moinbers of Family --Section 9 of the Civil Service Act provides that whenever there are already two or more members of a family serving under Mobational or permanent appointment in the competitive servine, no other member of such family in elig hur for probational or permanent appetitment in the competitive ser٧١٢٠ The appointments of persons entitled to veteran perference are nie subject to this requirement. The members of famly provuica does not apply to temporary apuntments. Doubtful waars may be referred to the appropriate office of the Civil Service Commamon for decision