[104-10224-10012.pdf — page 282]
Iseal. Hias: Refereneces from Outch.Please obtain copies of these references free Ise Ioutch.### ADDRESSED TO: RECRUITING DEPARTMENT, NYProfessor David Owen. History Dept, Harvard Univ,Cambridge, Mass. ProfessorMr. H.B. Fisher 564, Vour Rd., Woodridge, Conn. FarmerlyIndicate "YES" OR "NO" ANSWER BY PLACING "X" IN PROPER COLUMN.with F.B.I.|                                                                                                 | YES | NO  | INDICATE "YES" OR "NO" ANSWER BY PLACING "X" IN PROPER COLUMN                                                                                                                                                                                                                                                                                                               | YES | NO  || ----------------------------------------------------------------------------------------------- | --- | --- | --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | --- | --- || 25. MAY INQUIRY BE MADE CT YOUR PRESENT EMPLOYER PIGARDIANG YOUR CHARACTER QUALIFICATIONS, ETC? |     | X   | 35. ARE YOU AN OFFICIAL OR EMPLOYEE OF ANY STATE, TERRITORY, COUNTY OR MUNICIPALITY? If your answer is "Yes," dive details in Item 39                                                                                                                                                                                                                                       |     | X   || 26. ARE YOU A CITHIN OF OR DO YOU OWE ALLEGIANCE TO THE UNITED STATES?                          | X   |     | 36. DOES THE UNITED STATES GOVERNMENT EMPLOY IN A CIVILIAN CAPACITY ANY RELATIVE OF YOURS DY BLOOD OR MARRIAGE WITH WHOM YOU LIVE OR HAVE LIVED WITHIN THE PAST 24 MONTHS? If your answer is "Yes," show in Item 39 for EACH such relative: (1) full name; (2) present address; (3) relationship; (4) Department or Agency by which employed, arid (5) Aind of appointment. | X   |     || 27. ARE YOU NOW OR HAVE YOU EVER DIER OF THE COMMUNIST PARTY, I:5 A OR ANY COMMINIST ORGAN.     |     | X   |                                                                                                                                                                                                                                                                                                                                                                             |     |     || 28. ARE YOU NOW, OR HAVE YOU EVER LEAFASCIST ORGAN. ITAT1041                                    |     | X   |                                                                                                                                                                                                                                                                                                                                                                             |     |     |SPECIAL INSTRUCTIONS FOR CLAIMING VETERAN PREFERENCE29 ARE YOU NOW, OR HAVE YOU FED ANY ORGANIZATION, ASSOCIATION, MOVEMENT, GROUP OR COMBINATION. WHICH 43 VOCATES THE OCHIHROW OF OUR CONSTITUTIONAL FORM OF GOVERNMENT OR OF AN ORGANIZATION, ASSOCIATION PROWT ORGANIZATION OF PERSON WHICH HAS ADOPTED A FOLING OR APPROVING THE COMMISION OF ACTS OF FORCEY OTHER PEPOONS THEIR RIGHTS UNDER THE CONSTIT- SANSOR OF SLEM- ING TO ALTER THE FORM OF GOVERNMENT すしい。IATES OYUNCON. S:STUTIONAL MEANIf your answer to question 27, 28, ar 29 a is "yes," state in Item 39 the names of all such organizations, associations, movements, groups, or combination of persons and dates of membership. Give completede details of your activities therein and make any explanation you desire regarding your membership or activitime t30. SINCE YOUR 1874 BIRTHDAY, HATE YOU EVER ED ARRESTED, INDICIFO OR SUMMONED INTO COURT AS A DEFENDANT IN AL CRIMINAL PROCEEDING OR CONVICTED, FINED, OR IMPRISONED OR LACERATION OR MAVE YOU EVER ALEN ORDERŁO TO DEPOSIT BAIL RAL, FOR THE VIOLA- TION OF ANY LAW, POLICE HEGULATION OF OR IN A CITY ICUCING VINER TRAFFIC VIOLATIONS FOR WHICH A FIDE DA FORF 19 OR LESS WAS IMPOS(Di....If your answer is "Yes," fhst all asse en under Item 19 below. Give in each case (1) the date; (7) the nature of the offense or violation; (3) the sarsue and main of the court; (3) the penalty imposed, if any of other deposition of the case. H apparinted, your Angerprise niti tie raken31. HAVE YOU EVER UFEN DISCHARGLD. CROPLAN FOR MISCON- DUCT OR UNSATISFACTORY SERVICE FROM........ If your answer sa "Yes," give 17 the name and address of employer, date, and reason in each case.32. HAVE YOU EVER BEEN BARRED BY THE CERVICE COMMISSION FROM TAKING AAMINATIONS OR ACCEPTINCLAVICE APPOINTMENTS If your answer in "Yos." give dures of and reasons for such debarment in Item 39.33. HAVE YOU ANY PHYSICAL MANDICAP. DISTASE. OR OTILA DISABILITY WHICH SHOULD BE CONSIDERED IN ASSIGNING TO WOΗΚΙ.....If your answer is "Yes," give complete details in Item 2280 that consideration can bo given to your physical Ainess for the jah.34. DO YOU RECEIVE AN ANNUITY ΓΡΟΥ THE UNITED STATES OR DISTRICT OF COLUMDIA GOVERNMENT UNDER ANY ACTIFERIST ACT OF ANY PENSION OR OTHER COMPENSADON FOR MILITARY CRETAL SERVICE.....If your answer in "Yes." give complete details in Item 39."A. If you are claiming preference as a PRACETIME VETERAN who has leen awarded a compaian badge de service riolume DISABLED VST- ERAN, or the WIFE OF A DISABLED VETERAN, or as the WIDOW OF A WAR OR CAMPAION VETERAN, attach Veteran, Preference Cata CSC Form 14, together with proof bevitel therein.B. If you are WAR-TIME VETERAN not claiming disability preference. you should NOT submit your discharge with thite applicationPreference ב be tentatively credited to you and if appunted, you will be required to subit to the appointing officer prior to entry on duty, ruffusal evidence of separa- thun from active service in the armed forces of the United States in time of war.|                                                                                                                                                          | YES | NO  || -------------------------------------------------------------------------------------------------------------------------------------------------------- | --- | --- || 37; (4) WERE YOU EVER IN THE UNITED STATES MILITARY OR NAVAL SERVICE DURING TIME OF WARI                                                                 |     | X   || (B) IS THE WORD "HONORABEL" OR THE WORD "SATISFACTORY USED IN YOUR DISCHARGE OR SEPARATION PAPERS TO SHOW THE TYPE OF YOUR DISCHARGE OR SEPARATION...... |     | X   || (C) WAS SERVICE PERFORMED ON AN ACTIVE FULL TIME BASIS, WITH FULL MILITARY PAY AND ALLOWANCES                                                            | X   |     |DATE OF INTRY OR ENTRIES INTO SLAVICE 17 Feb 1963 DATE OF SEPARATION OR SEPARATIONS 17 Feb. 1946BRANCH OF SIRICI (Army, Navy. Marine Corps, Coast Guard, etc.) Army SERIAL W) (if none, fire grade or eating at time of separation) 1777,076|                                                                                                                                                                                          | YES | AJ  || ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | --- | --- || 39 A IF YOU SERVED IN THE UNITED STATES MILITARY OR NAVAL SERVICE RING PEACETIME ONLY. DID YOU PARTICIPATE IN A CAMPAISONOR EXPEDI- TION AND RECEIVE A CAMPAIGN DALGE OR SERVICE HIDDUMI |     | X   || (B) ARE YOU A DISABLED VETERANI If so, and you have not listed your disability in answer to Item 33. explain in Stern 39 below.                                                          |     | N   || (C)ARE YOU A VETEMAN'S WIDOW WHO HAS NOT REMAPPΙΣΩΣ..                                                                                                                                    |     | X   || ID ARE YOU THE WIFE OF A VETERAN WHO HAS A SERVICE CONNECTED ISABILITY WHICH DISALIFIS HIM FOR CIVIL SERVICE ADVENT                                                                      |     |     |THIS SPACE FOR USE OF APPOINTING OFFICER ONLYThe information contained in the answers to Questions 37 above has been resi hed by comparison with the discharge certificate va ......................................................................................, 19.Agency: Title:39. SPACE FOR DETAILED ANSALRS 10 OMER CONS (dicate item numbers to which answers apply).ITEM NO ITEM NO19. Spanish: Reading, Good; Speaking Fair; Understanding, FairIf more space is required, use paper the same size as this page. Write on each sheet your name, address, date of birth, and examination title. Attach to inside of this application.Before signing this application check back over it to make sure that you have answered ALL questions correctly. I CERTIFY that the statements made by me in this application are true, complete, and correct to the beat of my knowledge and belief, and are made in good faith.False statement on this application is punishable by Law (U. S. Code, Title 18, Section 80).Ace H. UblesSIGNATURE OF APPLICANT te, initial or inftiale, and surname). If female (Sign your name in INK (one giv preme Miss or Mrs. and if marries tricour own given name as "Mrs. Mary L. Dor")U. S. GOVERNMENT PRINTING OFFICE 18-43940-1