[104-10195-10003.pdf — page 94]
# 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)1436 21st Street N.W. Washington, D.C.&(4) DATE OF BIRTH (2) PLACE OF BIRTH (city and State/or city and foreign country) (C) STREET AND NUMBER, CITY AND STATE (D) TELEPHONE NO.9/07/31 Cleveland, Ohio Utica,(4) IN CASE OF EMERGENCY, PLEASE NOTIFY (E) RELATIONSHIPMrs. Geraldine Hilsher sister 1510 Brinkerhoff Ave.8. IF ANY RELATIVE OF YOURS (EITHER BY BLOOD OR MARRIAGE) WITH WHOM YOU LIVE OR HAVE LIVED WITHIN THE PAST 24 MONTHSIf so, for each such relative A in the blank below. If additional space is necessary, complete under Item 12.NAME POST OFFICE ADDRESS (1) POSITION (3) TEMPORARY OR NOT RELATIONSHIP MAR. SINGLE(Give street number, if any) (1) DEPARTMENT OR AGENCY IN WHICH (Check one)EMPLOYEDINDICATE ANSWER BY PLACING "X" IN PROPER COLUMN YES NO INDICATE ANSWER BY PLACING "X" IN PROPER COLUMN YES NO5 (1) ARE YOU A CITIZEN OF THE UNITED STATES OF AMERICA OR (2) AS A NATIVE OF AMERICAN SAMOA DO YOU OWE ALLEGIANCE TO THE UNITED STATES OF ALMERICA?X 10 (A) HAVE YOU EVER FILED A WAIVER OF LIFE INSURANCE COVERAGE UNDER THE FEDERAL EMPLOYEES' GROUP LIFE INSURANCE ACT?X6 ARE YOU AN OFFICIAL OR EMPLOYEE OF ANY STATE, TERRITORY, COUNTY, OR MUNICIPALITY?X (B) IF YOU HAVE FILED SUCH A WAIVER, HAS IT BEEN CANCELED OR REVOKED?If your answer is “Yes,” give details in Item 127. DO YOU RECEIVE OR HAVE YOU APPLIED FOR AN ANNUITY FROM THE UNITED STATES OR DISTRICT OF COLUMBIA GOVERNMENT UNDER ANY RETIREMENT ACT OR ANY PENSION OR OTHER COMPENSATION FOR MILITARY OR NAVAL SERVICE?   X 11 SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT:   A. HAVE YOU BEEN DISCHARGED FROM EMPLOYMENT BECAUSE:   (1) YOUR CONDUCT WAS NOT SATISFACTORY?   X   (2) YOUR WORK WAS NOT SATISFACTORY?   X   If your answer is “Yes,” give details in Item 129. HAVE YOU PAID ANY TAXES ON NARCOTIC, ILLICIT LIQUOR, WAS STATE LAW, COUNTY OR MUNICIPAL LAW VIOLATED?NOT INCLUDE TRAFFIC VIOLATIONS FOR WHICH A FINE OF $25 OR LESS WAS IMPOSED. ALL OTHER CHARGES MUST BE INCLUDED EVEN IF THEY WERE WAIVED.X B. HAVE YOU RECEIVED A LETTER OFFICIAL NOTIFICATION THAT:(1) YOUR CONDUCT WAS NOT SATISFACTORY?X(2) YOUR WORK WAS NOT SATISFACTORY?XIf your answer is “Yes” give in Item 12 for each case:(1) approximate date, (2) charges, (3) place, (4) action taken.SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT HAVE YOU BEEN BARRED FROM TAKING EXAMINATIONS ON ACCEPTING CIVIL SERVICE PERMANENT STATUS?X C. HAVE YOU BEEN DISCHARGED FROM THE ARMED SERVICES UNDER OTHER THAN HONORABLE CONDITIONS?If your answer to A, B, or C is “Yes,” give details in Item 12 as clearly as you can remember, including the name and address of employer, approximate date, and reasons in each case.If your answer is “Yes,” give dates of and reasons for such debarment in Item 1212. SPACE FOR DETAILED ANSWERS TO OTHER QUESTIONS (Indicate item numbers to which answers apply.)ITEM NO.INSTRUCTIONS 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, arrest, age, citizenship 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-13.U. S. GOVERNMENT PRINTING OFFICE 10-34190-5