[104-10224-10001.pdf — page 100]
# 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)3409 VALLEY DRIVE ALEXANDRIA. VA2. (A) DATE OF BIRTH (B) PLACE OF BIRTH (city and State or city and foreign country)30 APRIL 1917 MANCHESTER NEW HAMPSHIRE3. (A) IN CASE OF EMERGENCY, PLEASE NOTIFY (B) RELATIONSHIP (C) STREET AND NUMBER, CITY AND STATE (D) TELEPHONE NO.EILEEN. MAKSYMIEC WIFE 3409 VALLEY DR ALEX VA TE-682184. 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 24 MONTHS? YES:If so, for each such relative fill in the blanks below. If additional space is necessary, complete under Item 12.| NAME          | POST OFFICE ADDRESS (Give street number, if any) | (1) POSITION (2) TEMPORARY OR (3) DEPARTMENT OR AGENCY IN WHICH EMPLOYED | RELATIONSHIP  | MAR. RIED | SIN GLE || ------------- | ------------------------------------------------ | ------------------------------------------------------------------------ | ------------- | --------- | ------- || MARYANNLLOYD  | SEDGE WICK.ST                                    | LAWYER FULL TIME                                                         | SISTER INLAW  |           | ✓       || CHARLES LLOYD | NW WASH                                          | FAA LAWYER FULL TIME DEPTOF DEFENCE                                      | BROTHER INLAW |           | ✓       ||               |                                                  |                                                                          |               |           |         ||               |                                                  |                                                                          |               |           |         ||               |                                                  |                                                                          |               |           |         |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?                                                                                                                                                                                                                                                                                                                                                                         |  ✓  |     | 10. (A) HAVE YOU EVER FILED A WAIVER OF LIFE INSURANCE COVERAGE UNDER THE FEDERAL EMPLOYEES' GROUP LIFE INSURANCE ACT?                                     |     |  ✓  || 6. ARE YOU AN OFFICIAL OR EMPLOYEE OF ANY STATE TERRITORY, COUNTY, OR MUNICIPALITY? If your answer is "Yes," give details in Item 11.                                                                                                                                                                                                                                                                                                                                                                                         |  ✓  |     | (B) IF YOU HAVE FILED SUCH A WAIVER, HAS IT BEEN CANCELED OR REVOKED?                                                                                      |  ✓  |     || 7. DO YOU RECEIVE OR HAVE YOU APPLIED FOR AN ANNUITY FROM THE UNITED STATES OR DISTRICT OF COLUMBIA GOVERNMENT (EXCEPT ANY RETIREMENT ACT OR ANY PENSION OR OTHER COMPENSATION FOR MILITARY OR NAVAL SERVICE)? If your answer is "Yes," give details in Item 11.                                                                                                                                                                                                                                                              |  ✓  |     | 11. SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT: A. HAVE YOU BEEN DISCHARGED FROM EMPLOYMENT BECAUSE: (1) YOUR CONDUCT WAS NOT SATISFACTORY? |     |  ✓  || 8. SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT, HAVE YOU BEEN ARRESTED, CHARGED, OR HELD BY FEDERAL, STATE, OR OTHER LAW ENFORCEMENT AUTHORITIES, FOR ANY VIOLATION OF ANY FEDERAL LAW, STATE LAW, COUNTY OR MUNICIPAL LAW, OR ORDINANCE? DO NOT INCLUDE TRAFFIC VIOLATIONS FOR WHICH A FINE OF $25 OR LESS WAS IMPOSED. ALL OTHER CHARGES MUST BE INCLUDED EVEN IF THEY WERE DISMISSED. If your answer is "Yes," give in Item 12 for each case: (1) approximate date, (2) charge, (3) place, (4) action taken. |  ✓  |     | (2) YOUR WORK WAS NOT SATISFACTORY)                                                                                                                        |  ✓  |     || 9. SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT, HAVE YOU BEEN BARRED BY THE U. S. CIVIL SERVICE COMMISSION FROM TAKING EXAMINATIONS OR ACCEPTING CIVIL SERVICE APPOINTMENTS? If your answer is "Yes," give dates of and reasons for such debarment in Item 11.                                                                                                                                                                                                                                                  |     |  ✓  | B. HAVE YOU RESIGNED AFTER OFFICIAL NOTIFICATION THAT: (1) YOUR CONDUCT WAS NOT SATISFACTORY!                                                              |     |  ✓  ||                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               |     |     | (2) YOUR WORK WAS NOT SATISFACTORY?                                                                                                                        |  ✓  |     ||                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               |     |     | 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 approximate number of days) on which you received sick leave under this or a Federal12. SPACE FOR DETAILED ANSWERS TO OTHER QUESTIONS (Indicate item numbers to which answers apply).ITEM NO.TWENTY YEAR. ARMY RETITEM NO. 11RECEIVED SICK LEAVE UNDER FRA ACCOUNT|     | YES | NO  || :-: | :-: | :-: ||     |     |  ✓  |HAS WAIVER PERIOD COVERED BY EACH PAYMENT EXPIRED?-|     | YES | NO  || :-: | :-: | --- ||     |  ✓  |     |INSTRUCTIONS TO APPOINTING OFFICER.--You must determine appointment would be in conformance with the Civil Service Act, applicable Civil Service Rules and Regulations, and acts of Congress. This form should be checked for holding of office, pension, any record of recent discharge or arrest, age, appointment. 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.