[104-10224-10007.pdf — page 340]
# DECLARATION OF APPOINTEEThis form is to be completed before entrance on duty. Answer all questions. 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 (Street and number, and Street)   5351 29th St. N. W. WASHINGTON.D.C.2. (A) DATE OF BIRTH (B) PLACE OF BIRTH (city of town, and State or country)   1 MARCH 1926 MASON City Iowa3. (A) IN CASE OF EMERGENCY PLEASE NOTIFY (C) STREET AND NUMBER, CITY AND STATE (C) TELEPHONE NO.   MRS. Nell S. MiLer WIFE 5351 29th ST. N.W. EM2-3866   WAS hingtou, A.٢.4. DOES THE UNITED STATES 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 12 MONTHS?If additional space is necessary, complete under Item 10.| NAME | POST OFFICE ADDRESS (Give street number, if any) | (1) POSITION (2) TEMPORARY OR NOT (3) DEPARTMENT OR AGENCY IN WHICH EMPLOYED | RELATION- SHIP | MAR- RIED | SINGLE (Check one) || ---- | ------------------------------------------------ | ---------------------------------------------------------------------------- | -------------- | --------- | ------------------ ||      |                                                  |                                                                              |                |           |                    ||      |                                                  |                                                                              |                |           |                    ||      |                                                  |                                                                              |                |           |                    ||      |                                                  |                                                                              |                |           |                    ||      |                                                  |                                                                              |                |           |                    |INDICATE "YES" OR "NO" ANSWER BY PLACING "X" IN PROPER COLUMN|                                                                                                                                                                                                                                                                                                  | YES | NO  | ITEM NO | 10. SPACE FOR DETAILED ANSWERS TO OTHER QUESTIONS WRITE IN LEFT COLUMN NUMBERS OF ITEMS TO WHICH DETAILED ANSWERS APPLY || ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ | --- | --- | ------- | ----------------------------------------------------------------------------------------------------------------------- || 5. ARE YOU A CITIZEN OF OR DO YOU OWE ALLEGIANCE TO THE UNITED STATES?                                                                                                                                                                                                                           | X   |     |         |                                                                                                                         || 6. ARE YOU AN OFFICIAL OR EMPLOYEE OF ANY STATE, TERRITORY, COUNTY, OR MUNICIPALITY?                                                                                                                                                                                                             |     | X   |         |                                                                                                                         || If your answer is "Yes", give details in Item 10.                                                                                                                                                                                                                                                |     |     |         |                                                                                                                         || 7. DO YOU RECEIVE ANY ANNUITY FROM THE UNITED STATES OR DISTRICT OF COLUMBIA GOVERNMENT UNDER ANY RETIREMENT ACT OR ANY PENSION OR OTHER COMPENSA TION FOR MILITARY OR NAVAL SERVICE?                                                                                                            |     | X   |         |                                                                                                                         || If your answer is "Yes", give in Item 10 reason for retirement, that is, age, optional disability, or for reason of involuntary or inhabilitary separation after 3 years service, amount of retirement pay, and under what retirement act and rating, if retired from military or naval service. |     |     |         |                                                                                                                         || 8. SINCE YOU FILED APPLICATION OF SEEKING IN THIS APPOINTMENT HAVE YOU BEEN DISCHARGED, OR FORCED TO RESIGN, FOR MISCONDUCT OR UNSATIS- FACTORY SERVICE FROM ANY POSITION?                                                                                                                       |     | X   |         |                                                                                                                         || If your answer is "Yes", give in Item 10 the name and address of employer, date and reason in each case.                                                                                                                                                                                         |     |     |         |                                                                                                                         || 9. HAVE YOU BEEN ARRESTED (NOT INCLUDING TRAFFIC LAW VIATIONS FOR WHICH YOU WERE FINED 10$ OR LESS OR FORFEITED COLLATERAL) SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT?                                                                                                           |     | X   |         |                                                                                                                         || If your answer is "Yes", list all such cases under Item 10, including the nature of the charge. (1) the date. (2) the name of the court or other disposition of the case. If appointed, your fingerprints will be taken.                                                                         |     |     |         |                                                                                                                         |# INSTRUCTIONS TO APPOINTING OFFICERThe appointing officer before approving certificate shall determine to his own satisfaction that is appointment complies with the Civil Service Rules and Regulations and applicable Civil Service Act, applicable Civil Service Rules and Regulations pertaining to appointment.This form should be attached to booking officer (was a civil service action with any record of record discharge is erred, not precisely the following:(1) Identity of appointee will is the date of the employment agreement appointee and to determine he will transfer to the applicant in the appointee and considering appointee and questioning appointee. If the appointee will what purpose, the instrument will have copies to the appointee to the declaration about which he was signed in the from notice a more shall also be questioning but his positions. between of.(2) Age-definite age limits have been established for the position It should be determined that appointment do not violate the age range for appointment. Cat case, the appointments was and is commoncated.(3) (1) competent the appointee officer is responsible to the citizenship (including (1) of the Civil Service Rules and Regulation (1) competent an appointee will be the appointee will should not to be communitated 1 will always (8) the contrary side of the Civil Service Commission.(4) Minister of Family (1) (8) of the Civil Service Rules and Regulation provides that the appointee will always the more ministers of paramount of government are always 1 the Ministers of Family it been family. 1 the the Civil service commission for the more appointee. 1 the appointee will always he be informed of.