[104-10222-10002.pdf — page 136]
# DECLARATION OF APPOINTEEThis form is to be completed before entrance on duty. Question S is to be answered in all cases, otherwise answer only those questions which require an answer diferent from that given to the corresponding questions on your application form. Il no answers are diferent, write "NONE" in Item 10, below. 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 (etreet and number, erty and State)5733 Hamilton St, Apt 2, Rogers Heights, Md.2. (A) DATE OF BIRTH (B) PLACE OF BIRTH (oity of town and State se country)20 Jun '48 Tumayun, P.3. (A) IN CASE OF EMERGENCY PLEASE NOTIFY (B) RELATIONSHIP (C) STREET AND HUMBER, CITY AND STATE (C) TELEPHONE NOMrs. Wilma M. Christ Wife 5733 Hamilton St, Apt2 Rogers Heights, Md AP 3603-4. DOES THE UNITED STATES GOVERNMENT EMPLOY, IN A CIVILIAN CAPACITY, ANY RELATIVE OF YOURS (ITWER BY BLOOD OR MARRIAGE) WITH WHOM YOU LIVE OR NAVE LIVED WITHIN THE PAST 24 MONTHSP YES NOIl so, for sach such relativo All in the blanks below. Il additional space is necessary complete under Item 10.| NAME | POST OFFICE ADDRESS (Give street number, if any) | ANTAWC) TEMPORARY OR NOT DEFARTMENT OR AGENCY IN WHICH EMPLOYED | RELATION SHIP | MAR RIED (Chook one) | SINGLE || ---- | ------------------------------------------------ | --------------------------------------------------------------- | ------------- | -------------------- | ------ ||      |                                                  |                                                                 |               |                      |        ||      |                                                  |                                                                 |               |                      |        ||      |                                                  |                                                                 |               |                      |        |INDICATE "YES" OR "NO" ANSWER BY PLACING "X" IN PROPER COLUMN 10. SPACE FOR DETAILED ANSWERS TO OTHER QUESTIONS|                                                                                                                                                                                                                                                                                                                                       | YES | NO  | ITEM NO. | WSITE IV LEFT COLUMN NUMARAS OF ITEMS TO WHICH DETAILED ANSHERS APPLY || ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | --- | --- | -------- | --------------------------------------------------------------------- || 5. ARE YOU A CITIZEN OF ON DO YOU OWE ALL EGIANCE TO THE UNITED STATESI...                                                                                                                                                                                                                                                            |     |     |          |                                                                       || 6. ARE YOU AN OFFICIAL OR EMPLOYES OF ANY STATE, TERRITORY, COUNTY, OR MUNICIPALITY!.......                                                                                                                                                                                                                                           |     |     |          |                                                                       || If your answer is "Yos", give details in fremm 10.                                                                                                                                                                                                                                                                                    |     |     |          |                                                                       || 7. DX) YAJ RLEPIF ANY ANNUITY FROM THE MED STATES OR DIATRICT OF COLUMBIA GOVERNMENT UNDER ANY RETIRI VENT ACE OR ANY PEGION OR OFHLA CUMPENSATION FOR MISTRY MALAL SERVICE                                                                                                                                                           |     |     |          |                                                                       || It your answer in "You", dive in itens to ream for roliramoil, that is, agn, optional disability, or area of voluntary or involuntary operation after 5 yairs' merce; amount of zolironment pay, and under what retirement aut, and ratingA, if retired from muhtary or naval                                                         |     |     |          |                                                                       || 8. HAVE YOU EVER BEEN EISCHARGED OR FORM STRESIGN, FOR MISCONDUCT OR UNSATISFACTORY SINVICLE FROM ANY FA                                                                                                                                                                                                                              |     |     |          |                                                                       || 11 your anan or is "You", are in Itam l the name and address ul amplayer, date, and reason in oava                                                                                                                                                                                                                                    |     |     |          |                                                                       || 9. SINCE YOUR 16EN FIRTHDAY, HAVE YOU DER MEN ARRESTED INDICTED, OR SUMMONED INTO COURT AS A DEFENDANT IN A CRIMINAL PROLELL, CONVICTIO FINED GRIMPHIOR FLALEDON PROLATION OF HAVE YOR! EYLA M'N OROLLED TO PROTBALL CLLLLLL OF ANT LAW POLICE REGULATAN ORANG MING FIC VIOLATIORS FOR WHILEHAPINE OR FORTUNE FORLESS WASIO VIOLATION |     |     |          |                                                                       || Il vour answer is "Yes", list all such casas under Item 10. Dive in nach cano (1) lho datu. (4) the nature of the offens or violation; (3) the name and water o court, (1) the penalty imposed, if any, or otherion of the. Il appointed, youe Angerprints will a saken                                                               |     |     |          |                                                                       |# INSTRUCTIONS TO APPOINTING OFFICERThe appointing officer before whom the foregoing certificate is made shall determine to his own zatiafaston that this entinent would be in conformance with the Civil Service Act, appheab'e Cal Sathe Rules and Regulations and acts of Congress pertaining to appointment.The form should be checked for holding the penelor, entability in cun nection with any resort of recent is harge or arreat, and particularly for the following:(1) Identity of appointes -The applate's signature and handwriting arM to he compared with the appsatser her pertinent papere. The physical appearence may be checked against the medical certineate, Tho appetitre may also be questioned ca hia permaal sustory for agreement with his previous staletuct.ts.(2) Ago. If definite age limits have been established for the postion, it should be determined that appleant is not cute the age range for appointment. Uati sucla determination laaste the antay aot be consufuriated,(3) The appointing officer is responsible for observing the (1) the Civ.d Service Rules and rata acts Fドリシジバム An ardent for both purtareptaise proof of arp shut pot de consummated und learname has been award from the ceregrassic of the Civil Sence Comunisain,(4) Memes of Family. -Section of the Civil Service Act provides that whrashere are already two or more members of a fair serung wider prese permanent appwutmeat in the competitive active, as other imember of duty is eligible for probatural or permanent praent in the いいって、 The appointarenes of peccons cancel to beteren petrece as a subiect to this requirement, The members taauly provision dos porervantments, Domorral cases may be serred to the page adve of the Ovil Servwe Commuanen for han![G. S. GOVERNMENT POINTING CHIC]