[104-10194-10023.pdf — page 27]
# DECLARATION OF APPOINTEEThis form, if required, is to be completed before entrance on duty. Every question must be answered. Any false statement in this declaration will be grounds for cancellation of application or dismissal after appointment. False personation is a criminal offense and will be prosecuted accordingly.1. Present Address: _So. Willett St. Albany, N.Y._2. Who should be notified in case of emergency? _Mrs. E.G. Blunt Menands_3. Does the U. S. 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 8 months? Yes or No. If so, list each such relative bill in the blanks below. If additional space is necessary, complete under item 12.| Name | Post-office address (Give street number, if any) | Position and (2) Temporary or nrd, and (3) Department or office in which employed | Relationship | Married or Single | Age || ---- | ------------------------------------------------ | --------------------------------------------------------------------------------- | ------------ | ----------------- | --- || 1.   |                                                  |                                                                                   |              |                   |     || 2.   |                                                  |                                                                                   |              |                   |     || 3.   |                                                  |                                                                                   |              |                   |     || 1.   |                                                  |                                                                                   |              |                   |     || 2.   |                                                  |                                                                                   |              |                   |     || 3.   |                                                  |                                                                                   |              |                   |     || 1.   |                                                  |                                                                                   |              |                   |     || 2.   |                                                  |                                                                                   |              |                   |     || 3.   |                                                  |                                                                                   |              |                   |     |4. Place of birth: _Hamburg, Erie County, N.Y._Indicate "Yes" or "No" answer by placing X in proper column:|                                                                                                                                                                                                                                                                                                                                                                                                                 | Yes | No  || --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | :-: | :-: || 5. Are you a citizen of the United States?                                                                                                                                                                                                                                                                                                                                                                      |  X  |     || 6. If foreign born, have you furnished proof of naturalization or citizenship to (1) the U. S. Civil Service Commission? (2) this agency in connection with this appointment?                                                                                                                                                                                                                                   |     |  X  || 7. Since you filed application resulting in this appointment, has there been any change in the status of your citizenship, or of the persons through whom you obtained your citizenship?                                                                                                                                                                                                                        |     |  X  || 8. (a) Do you hold any position or office under the United States or any State, Territory, County, or Municipality? If so, state the place, position, and salary under item 12.                                                                                                                                                                                                                                 |     |  X  || (b) Are you willing to resign such position or office if it becomes necessary to do so in order to hold the Federal position?                                                                                                                                                                                                                                                                                   |  X  |     || 9. Do you receive any pension or other benefit for military or naval service or an annuity from the U.S. or D.C. Government under any Retirement Act? If so, give details under item 12 whether you were retired for age, length of service, or disability; amount of retirement pay and under what retirement act and rank, if retired from military or naval service.                                         |     |  X  || 10. Since you filed application resulting in this appointment, have you been discharged for misconduct or unsatisfactory service, or forced to resign there from? If so, give under Item 12 where employed, name and address of employer and the reason for discharge in each case.                                                                                                                             |     |  X  || 11. Since you filed application resulting in this appointment, have you been arrested or summoned into any civil or military court as a defendant, or indicted for or convicted of any offense (felony or misdemeanor)? If so, for each case give under item 12 (1) the name and location of the court, (3) the nature of the offense or violation, and (4) the penalty, if any, imposed, or other disposition. |     |  X  |12. Space for detailed answers to other questions.    Write in left column numbers of items to which detailed answers applyITEM NO. ECA Information SpecialistCAF 12 $5905.20# INSTRUCTIONS TO APPOINTING OFFICERThe appointing officer before whom the foregoing certificate is made shall determine to his own satisfaction that as appointment would be in conformance with the Civil Service Act, applicable civil-service rules, the War Service Regulations, and acts of Congress pertaining to appointment.This form should be checked for hold up of active pension, purchase of office, suits in connection with any record of recent discharge or arrest, promises to observe provisions regarding personal integrity, and particularly for the following:(1) Identity of appointee with the applicant whose appointment was authorized. The appointee's signature and handwriting are to be compared with the application and/or other pertinent papers. The personal appearance may be checked against the medical record. The appointee may also be questioned on his personal history for agreement with his previous statements.(2) Age. If discrepancy exists between the date of birth and that on application and if definite age limits have been established for the position, it should be determined that applicant is not outside the age range for appointment.(3) Citizenship. The responsibility for observance of appropriation acts prohibiting or restricting the employment of aliens lies with the appointing officer. The Civil Service Commission indicates on applications showing foreign birth that citizenship has been verified. The appointing officer should verify citizenship at the list of eligibles or the letter of authority from the Commission makes the appointment subject to proof of citizenship, or if the application shows foreign birth but does not indicate on its face that citizenship has been proved. If the answer to question 5 of this form shows foreign birth and the application shows birth in the United States, the case should be referred to 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 the family in the classified service, no other member of such family is eligible for appointment in that service. Minors do not establish a different family merely by living at an address different from that of the parents. Doubtful cases involving more than three members of a family, mail permanent evidence should be reported to the Civil Service Commission or its duly authorized representatives for decision. Under War Service Regulations the members provision does not apply to temporary appointments for one year or less.