[104-10224-10006.pdf — page 226]
# 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.823 Asitic-River-Alamlea-CaliforniaPRESENT ADDRESS (street and number, city and State)(2) DATE OF BIRTH: Jan 26, 1924(3) PLACE OF BIRTH (city or town and State of country): Waurika, Oklahoma(5) IN CASE OF EMERGENCY PLEASE NOTIFY:Ruth 1950(a) NAME(b) RELATIONSHIP: Wife(c) STREET AND NUMBER, CITY AND STATE: 820 Pacific Ave, Alameda, california(d) TELEPHONE NO.: Unknown: 3-46496. 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? YES [X] NO [ ]If so, for each such relative list in the blanks below. If additional space is necessary, complete under Item 10.|     | NAME | POST OFFICE ADDRESS (Give street number, if any) | (1) RELATION (2) TEMPORARY OR NOT (3) DEPARTMENT OR AGENCY IN WHICH EMPLOYED | RELATIONSHIP | MAR.  RIED (Check one) SINGLE || --- | ---- | ------------------------------------------------ | ---------------------------------------------------------------------------- | ------------ | ----------------------------- || 1.  |      |                                                  |                                                                              |              |                               || 2.  |      |                                                  |                                                                              |              |                               |INDICATE "YES" OR "NO" ANSWER BY PLACING "X" IN PROPER COLUMN|                                                                                                                                                                                                                                                                                                       | YES | NO  | 13. 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 COMPENSATION FOR MILITARY OR NAVAL SERVICE?                                                                                                                  |     | [X] |                                                                                                                         || If your answer is "Yes", give in Item 10 reason for retirement, that is, age, optional disability, or by reason of voluntary or involuntary separation after 3 years' service; amount of retirement pay; and rank and serial number, date and rating, if retired from military or naval service.      |     |     |                                                                                                                         || 8. SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT, HAVE YOU BEEN DISCHARGED OR FORCED TO RESIGN FOR MISCONDUCT OR UNSATISFACTORY SERVICE FROM ANY PREVIOUS EMPLOYER?                                                                                                                       |     | [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 FOR INDIGNANT TRAFFIC VIOLATIONS FOR WHICH YOU WERE FINED 50 OR MORE OR INCARCERATED, OR UNLESS SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT?                                                                                                                  |     | [X] |                                                                                                                         || If your answer is "Yes", list all such cases under Item 10. Give in each case: (1) The date and (2) the nature of the offense or violation. (3) the name and address of the court: (4) the penalty imposed, if any; (5) other disposition of the case. If appointed, your fingerprints will be taken. |     |     |                                                                                                                         || 1.                                                                                                                                                                                                                                                                                                    |     |     |                                                                                                                         || 2.                                                                                                                                                                                                                                                                                                    |     |     |                                                                                                                         |INSTRUCTIONS TO APPOINTING OFFICERThe appointing officer before the foregoing certificate is made shall determine to his own satisfaction that this appointment would be in conformity with the Civil Service Act, and the Civil Service Rules and Regulations and material.This form should be (before the beginning of office, position, matriculation or appointment with any) record of interest (or investigation) following:(1) Identity of appointee. -If it is the date of the appointing officer to guard against impersonation not to be over-concerned as to detail or exactness in some person's name, and other associates' impressions have come are to be compared with the applicant's impression as to the signature on this form.(2) Other information.-It should be signed as a "Declaration" and should be questioned on his private history by a departmental or agency representative.(1) Age -If definite age limits have been established for the position, it should be determined that applicant is well within the age range for appointment or matriculation. The appointment may be recommenced.(2) Citizenship.- The appointing officer in ascertaining citizenship of an official of the Civil Service is hereby authorized to rely on official status in the absence of conflicting evidence. In no decision above the Civil Service Laws has been reversed hence by action.(3) Magnanimity. -Section 9 of the Civil Service Act provides that agency must have provisions of a family serving under its direction and that the government service is professional in character and is not departmental or agency to be referred to in the civil service because of the nature.