[104-10225-10003.pdf — page 344]
14-00000FORM 581451RECORD OF OVERSEAS SERVICENAME OF EMPLOYE::EMPLOYEE SERIAL NOCOMPLETED BY EMPLOYEE:TELEPHONE EXTSECRET (WHEN FILLED IN)INSTRUCTIONS:THIS FORM MUST BE RETURNED WHETHER YOU HAVE HAD OVERSEAS SERVICE OR NOT.PLEASE READ CAREFULLY INSTRUCTIONS ON ACCOMPANYING CARD, THEN FILL OUT THIS FORM AS ACCURATELY AS POSSIBLE.DO NOT FOLD STAPLE, SPINDLE, OR MUTILATEWHERE SERVICE WAS PERFORMEDTYPE SERVICEDATESSERVICE ASRESPONSIBLE U.S. GOV'T DEPT. OR AGENCYDO NOT WRITE IN COLUMNFROMTOCIVILIAN 1MILITARY-2450 Mitica 1126777031 CIA 100IF ADDITIONAL SPACE IS NEEDED, CHECK HERE AND ASK YOUR ADMINISTRATIVE OFFICER FOR SUPPLEMENTAL CARDSSECRETINDICATE ANSWER BY PLACING "X" IN PROPER COLUMNYESNOINDICATE ANSWER BY PLACING "X" IN PROPER COLUMNYESNO5. (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?X10. (A) HAVE YOU EVER FILED A WAIVER OF LIFE INSURANCE COVERAGE UNDER THE FEDERAL EMPLOYEES' GROUP LIFE INSURANCE ACT?X6. 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?XIf your answer is "Yes," give details in Item 12.7. 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?X11. SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT:A. HAVE YOU BEEN DISCHARGED FROM EMPLOYMENT BECAUSE:(1) YOUR CONDUCT WAS NOT SATISFACTORY?XIf your answer is "Yes," give details in Item 12.(2) YOUR WORK WAS NOT SATISFACTORY?X8. 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, REGULATION 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.XB. HAVE YOU RESIGNED AFTER OFFICIAL NOTIFICATION THAT:(1) YOUR CONDUCT WAS NOT SATISFACTORY?X(2) YOUR WORK WAS NOT SATISFACTORY?XIf your answer is "Yes," give in Item 12 for each case (1) approximate date, (2) charge, (3) place, (4) action taken.C. HAVE YOU BEEN DISCHARGED FROM THE ARMED SERVICES UNDER OTHER THAN HONORABLE CONDITIONS?X9. 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?XIf 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 case.If your answer is "Yes", give dates of and reasons for such debarment in Item 12.12. SPACE FOR DETAILED ANSWERS TO OTHER QUESTIONS (Indicate item numbers to which answers apply)ITEM NOITEM NOINSTRUCTIONS TO APPOINTING OFFICER. - You must determine that this appointment would be in conformance with the Civil Service Act, applicable Civil Service Rules and Regulations, and acts of Congress pertaining to appointment.This form should be checked for holding of office, pension, any record of recent discharge or arrest, age, citizenship, and members of family. 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 (1) his physical appearance against the medical certificate.1:3A3