[104-10194-10026.pdf — page 233]
# DECLARATION OF APPOINTEEThis form is to be completed before entrance on duty. Answer all questions. Admitted unfavorable information about such matters as arrests or discharges will be considered together with the favorable information in your record in determining your present fitness for Federal employment. However, a false statement or dishonest answer to any question may be grounds for dismissal after appointment and is punishable by. law.1. PRESENT ADDRESS (street and number, city and State)ALGAN TOWERS - 3500 MASS. Ave. WASHINGTON, D.C.2. (A) DATE OF BIRTH (B) PLACE OF BIRTH (city and State or city and foreign 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 N. PHILLIPS WIFE ALGAN TOWERS WOL-64003500 MASS. Ave., WASH,D.C4. DOES THE UNITED STATES GOVERNMINTAMPLOY, IN A CIVILIAN CAPACITY, ANY RELATIVE OF YOURS (EITHER BY BLOOD OR MARRIAGE) WITH WHOM YOU LIVE OR HAVE LIVED WITHIN THE PAST 24 MONTHS? YES NOIf so, for each auch relative hil in the blank below If additional space is necessary, complete under Item 12.| NAME | POST OFFICE ADDRESS (Give street number, if any) | (1) POSITION (2) TIMPORARY OR NOT (3) LEPARTMENT OR AGENCY IN WHICH EMPLOYID | RELATIONSHIP | MAR. RIFO (Check one) || ---- | ------------------------------------------------ | ---------------------------------------------------------------------------- | ------------ | --------------------- ||      |                                                  |                                                                              |              |                       ||      |                                                  |                                                                              |              |                       ||      |                                                  |                                                                              |              |                       ||      |                                                  |                                                                              |              |                       ||      |                                                  |                                                                              |              |                       ||      |                                                  |                                                                              |              |                       || INDICATE ANSWER BY PLACING "X" IN PROPER COLUMN                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   | YES | NO  | INDICATE ANSWER BY PLACING "X" IN PROPER COLUMN | YES | NO  || --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | --- | --- | ----------------------------------------------- | --- | --- || 5. (A) ARE YOU A CITIZEN OF THE UNITED STATES OF AMERICA, OR (B) AS A NATIVE OF AMERICAN SAMOA DO YOU OWE ALLEGIANCE TO THE UNITED STATES OF AMERICA?                                                                                                                                                                                                                                                                                                                                                                             |     | x   |                                                 |     |     || 6. ARE YOU AN OFFICIAL OR EMPLOYEE OF ANY STATE, TERRITORY, COUNTY, OR MUNICIPALITY? If your answer is "Yes," give details in Item 12.                                                                                                                                                                                                                                                                                                                                                                                            |     | x   |                                                 |     |     || 7. DO YOU RECEIVE OR HAVE YOU APPLHO FOR AN ANNLITY FROM THE UNITED STATES OR DISTRICT OF COLUMBIA GOVERNMENT UNDER ANY RETIREMENT ACT OR ANY PENSION OR OTHER COMPENSΑΤΙΟΝ ΓΟΗ MILITARY OR NAVAL SERVICET If your answer is "Yes," give details in Item 12                                                                                                                                                                                                                                                                       |     | x   |                                                 |     |     || 8. SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT HAVE YOU BEEN ARRESTED CHARGED OR HILD BY FEDERAL, STATE OR OTHER LAW ENFORCEMENT AUTHORITIES FOR ANY VALATRIN OF ANY FEDERAL LAW, STATE LAW, COUNTY OR MUNICIPAL LAW, REGULATION OR ORDINANCET DO NOT INCLUCE TRAFFIC VIOLATIKIN', FOR WHILA FINE OF 125 OR LESS WAS IMPOSED ALL OTHER CHARGES MUST BE INCLUDED EVEN IF THEY WERE DISMISSED If your answer is "Yos," give in Itein 12 for each case: (1) approximate date, (2) charge, (3) place, (4) action taken. |     | x   |                                                 |     |     || 9. SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT, HAVE YOU BEEN BARRED BY THE U S. CIVIL SERVICE COMMISSRIN FROM TAKING EXAMINATIONS OR ACCEPTING CIVIL SERVICE APPOINTMENTS? If your answer is "Yes." five dates of and reasons for such debarment in Item 12.                                                                                                                                                                                                                                                       |     | x   |                                                 |     |     || 10. (A) HAVE YOU EVER FILED A WAISER OF LIFE INSURANCE COVERAGE UNDER THE FELHAL EMPLOYEES GROUP LIFE INSURANCE ACTI                                                                                                                                                                                                                                                                                                                                                                                                              | x   |     |                                                 |     |     || (B) IF YOU HAVE FILED SUCH A WAIVER, HAS IT BEEN CANCELED OR REVURED?                                                                                                                                                                                                                                                                                                                                                                                                                                                             |     | x   |                                                 |     |     || 11. SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT A. HAVE YOU BEEN DISCHARGED FROM EMPLOYMENT BECAUSE (1) YOUR CONDUCT WAS NOT SATISFACTORY? (2) YOUR WORK WAS NOT SATISFACTORY?                                                                                                                                                                                                                                                                                                                                      |     | x   |                                                 |     |     || B. HAVE YOU RESIGNED AFTER OFFICIAL NOTIFICATION THAT: (1) YOUR CONDUCT WAS NOT SATISFACTORY? (2) YOUR WORK WAS NOT SATISFACTORY?                                                                                                                                                                                                                                                                                                                                                                                                 |     | x   |                                                 |     |     || C. HAVE YOU BEEN DISCHARGED FROM THE ARMED SERVICES UNDER OTHER THAN HOMURABLE CONDITIONST If your answer to A, B, or C is "Yes," Live details in Item 12 salearly as you can remember, including the name and address of employer, approximate date, and rosaune in each case                                                                                                                                                                                                                                                    |     | x   |                                                 |     |     |12. SPACE FUN DETAILED ANSWERS TO OTHER QUESTIONS (Irdicate item Rumbers to which answers apply)ITEM NO.ITEM NOINSTRUCTIONS TO APPOINTING OFFICER. You must determine 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 checked for holding of office, pension, any record of recent discharge or arrest, age, citizensl.ip, and members of family. Also, to establish the identity of the appointee, you should particularly check (1) his signature and handwriting against the application and 'or other pertinent papers and (2) his physical appearance against the medical certificate.