[104-10225-10006.pdf — page 270]
# 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)3828 CONNECTICUT AN N6, #205, WASHINGTON S, R.C.2 (A) DATE OF BIRTHAUGUST H. 1935(B) PLACE OF BIRTH (city and State of city and foreign country)SAN MARCOS, TEXAS3 (A) IN CASE OF EMERGENCY, PLEASE NOTIFYMRS. DORRIS TILLES(B) RELATIONSHIPWIFE(C) STREET AND NUMBER, CITY AND STATE2928 CONNECTICUT AUT., #5-7-5404A.W., NASH, S, D.C 265-55224 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 blank below If additional space is necessary, complete under Item 12| NAME | POST OFFICE ADDRESS (Give street number, if any) | (1) POSITION (2) TEMPORARY OR NOT (3) DEPARTMENT OR AGENCY IN WHICH EMPLOYED | RELATIONSHIP | MAR. SINGLE (Check one) || ---- | ------------------------------------------------ | ---------------------------------------------------------------------------- | ------------ | ----------------------- ||      |                                                  |                                                                              |              |                         ||      |                                                  |                                                                              |              |                         ||      |                                                  |                                                                              |              |                         ||      |                                                  |                                                                              |              |                         |INDICATE ANSWER BY PLACING "X" IN PROPER COLUMN YES NO INDICATE ANSWER BY PLACING "X" IN PROPER COLUMN YES NO5 (A) ARE YOU A CITIZEN OF THE UNITED STATES OF AMERICA OR (B) AS A NATIONAL OF AMERICAN SAMOA DO YOU OWE ALLEGIANCE TO THE UNITED STATES OF AMERICA?[X]10 (A) HAVE YOU EVER FILED A WAIVER OF LIFE INSURANCE COVERAGE UNDER THE FEDERAL EMPLOYEES GROUP LIFE INSURANCE ACT?[X]6 ARE YOU AN OFFICIAL OR EMPLOYEE OF ANY STATE, TERRITORY, COUNTY, OR MUNICIPALITY?[X](B) IF YOU HAVE FILED SUCH A WAIVER, HAS IT BEEN CANCELED OR REVOKED?[X]If your answer is "Yes," give details in Item 127 DO YOU RECEIVE OR HAVE YOU APPLIED FOR AN 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]11 SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT, A. HAVE YOU BEEN DISCHARGED FROM EMPLOYMENT BECAUSE:(1) YOUR CONDUCT WAS NOT SATISFACTORY?[X](2) YOUR WORK WAS NOT SATISFACTORY?[X]If your answer is "Yes," give details in Item 128 SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT, HAVE YOU BEEN ARRESTED, CHARGED (OR HELD) BY FEDERAL, STATE, (OR MUNICIPAL LAW ENFORCEMENT AUTHORITIES FOR ANY VIOLATION OF ANY FEDERAL, STATE, (OR LOCAL) STATUTE, LAW, (OR REGULATION (INCLUDING TRAFFIC VIOLATIONS) FOR WHICH A FINE OF $25.00 (OR MORE) (OR ITS EQUIVALENT IN COMMUNITY SERVICE) WAS IMPOSED OR ALL OTHER CHARGES WERE REDUCED EVEN IF THEY WERE DISMISSED?[X]B. HAVE YOU RESIGNED AFTER OFFICIAL NOTIFICATION THAT:(1) YOUR CONDUCT WAS NOT SATISFACTORY?[X](2) YOUR WORK WAS NOT SATISFACTORY?[X]C. HAVE YOU BEEN DISCHARGED FROM THE ARMED SERVICES UNDER OTHER THAN HONORABLE CONDITIONS?[X]If your answer is "Yes," give details in Item 12 the exact amount, (1) approximate date (2) charge, (3) place, (4) action taken.If your answer to A, B, or C is "Yes," give details in Item 12 as clearly as you can remember, including the name and address of employer, approximate date, and reasons in each case9 HAVE YOU EVER FILED APPLICATION RESULTING IN THIS APPOINTMENT HAVE YOU BEEN DISCHARGED FOR FAILURE TO MEET TRAINING REQUIREMENTS OR FOR MISCONDUCT IN THE U.S. ARMED FORCES?[X]If your answer is "Yes," give dates of and reasons for such discharges in Item 12INSTRUCTIONS TO APPOINTING OFFICER: You must determine that the appointment would be in conformance with the Civil Service Act, Executive Orders and Regulations and must, if in doubt, prefer charges pertaining to appointment. This form should be attached to the backing of office, permanent record of record of record of record of record against appointee's name on the card 397-A. This form should permanently attach (1) his signature and handwriting against the application and attach permanent papers and (II) his signature against master card conductors.