[104-10225-10007.pdf — page 201]
# 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 ADORESS (street and number, city and State)CARILLEN HOUSE, 2500 WISCONSIN ARS.N.W. Wash. D.C2. (A) DATE OF BIRTH (B) PLACE OF BIRTH (city of town and State or country)MAR 13, 1925 AUBURN, NEW YORK3. (A) IN CASE OF EMERGENCY PLEASE NOTIFY (B) RELATIONSHIP (C) STREET AND NUMBER, CITY AND STATE (2) TELEPHONE NOEARL Williamson Father 41 First Ave, AUBURN, N.Y.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 24 MONTHS?YES NOIf so, for each such relative fill in the blanks below. If additional space is necessary, complete under Item 10.| NAME | POST OFFICE ADORESS (Give street number, if any) | (1) POSITION (2) TEMPORARY OR NOT (3) DEPARTMENT OR AGENCY IN WHICH EMPLOYED | RELATIONSHIP | MARRIED 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? If your answer is "Yes", give details in Item 10.                                                                                                                                                                                                                                                                                                                                                     |     | X   |          |                                                                                                                         || 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?... If your answer is "Yes", give in Item 10 reason for retirement, that is, age, optional disability, by reason of voluntary of involuntary separation after 5 years' service, amount of retirement pay, and under what retirement act, and rating if retired from military or naval service.         |     | X   |          |                                                                                                                         || 8. SINCE YOU FILED APPLICATION RES.R TING IN THIS APPOINTMENT HAVE YOU BEEN DISCHARGED OR FORCED TO RESIGN FOR MISCONDUCT OR UNSATIS- FACTORY SERVICE FROM ANY POSITA'.... If your answer is" You", give in Item 10 the name and address of employer, date and reason in such case                                                                                                                                                                                                         |     | X   |          |                                                                                                                         || 9. HAVE YOU BEEN ARRESTED (NOT INCLUDING TRAFFIC VIOLATIONS FOR WHICH YOU WERE FINED $25 OR LESS OR COMMITTED COLLATERAL OF $25 OR LESS) SINCE YOU FILED APPLICATION RESULTS IN THIS APPOINTMENTt. Il your answer is "Yes", bat all such cases under Item 10. Qire in each rass (1) The date. (2) the nature of the offense or volatwn. (3) the name and Avatns of the court. (d) the penalty impused, if any. of other aposten of the case. If appointed, your Angerprints will be takes. |     | X   |          |                                                                                                                         |INSTRUCTIONS TO APPOINTING OFFICERThe appointing officer before when the foregoing certificate is made shall determine to his of satisfaction tashant nast uit to innal vamae wuh the Civil at Act, spphate Cined theirne Ruits and Regulations and and Crogress pertaining to uwwat meat.This form should be the trial be habee of office, person, suatiaty la come aluerng:(1) Identity od spines the duty of the apexisting offs of to guard egmost perawatter resonate dult Ihat the (2) ١٢- م definite age limits have been established the the pairka, it should he Jetermine that applicant is not cutsale the age reagerentment, Vatus & determination is made, the appuntment may ase be consummated.(Crensha The apparatetering tha stimen op of (1) the Civil Servue Rules and (2) Firm of caritates an affiavit for tath puredecodes of sitiarmpalatus in the aberme of contacting estrar. 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