[104-10225-10003.pdf — page 334]
# 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 AUDR33 (sfreet and number, cils and Statel1100 6th Street S.W Washington 1.4, D.C.1 (A) DATE OF BIRTH (B) PLACEBIRTH (city and State of city city and foreign country)8 Dec 35 Yonkers, New YORK8 (A) IN CASE OF EMERGENCY, PLEASE NOTIFY (C) STREET ANG NUMBER, CITY AND STATE (0) TELEPHONE ΜΟMRS. Joseph Piccolo 1636 N.E2057. LO 4-5834FTILALDSEDALS, FIR.& DOES THE UNITED STATES GOVERNMENT EMPLOY, IN A CIVILIAN CAPACITY ANY RELATIVE OF YOURS (FITHER BY BLOOD OR MARRIAGE) WITH WHOM YOU LIVE OR HAVE LIVED WITHIN THE PAST 24 MONTHST YES NOIl no, for each such relative hil in the blank below. Il additional space is necessary, complete under liem 12.| NAME | POST COFICE ADDRESS (Give street number, if any) | (1) M (7) TEMPORARY OR NOT 8 | (1)CAPARTMENT OR AGENCY IN WHICH EMPLOYED | RELATIONSHIP | MAR. RIFD GLE (Check one) || ---- | ------------------------------------------------ | ---------------------------- | ----------------------------------------- | ------------ | ------------------------- ||      |                                                  |                              |                                           |              |                           ||      |                                                  |                              |                                           |              |                           ||      |                                                  |                              |                                           |              |                           ||      |                                                  |                              |                                           |              |                           ||      |                                                  |                              |                                           |              |                           ||      |                                                  |                              |                                           |              |                           |INDICATE ANSWER BY PLACING "X" IN PROPER COLUMN YES NO INDICATE ANSWER BY PLACING "X" IN PROPER COLUMN YES NO1.(A) ARE YOU A CITIZEN OF THE UNITED STATES OF AMERIKA OR (8) AS A NATIVE OF AMERICAN SAMOA DO YOU OWE ALLEGIANCE TO THE URITED STATES OF AMERICAARE YOU AN OFFICIAL OR EMPLOVEE OF ANY STATE, TERRITORY, COUNTY, OR MUNICIPALITY!Il your answer is "You," give detaile in Item 121. DO YOU RECEIVE OR HAVE YOU APPLIFO FOR AN AMITY THE WAITED STATES OR LAS FRICT OF COLUMBIA GOVERNMENT UNDER ANY RET DE MENT ACT OR ANY PENSION OR OTHER COMPENSATION FOR MILITARY GARRA AL SERVICETyour anewer is "You," give details in Item 1211.you SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT, HAVE YOU BEN ARRESTED, CHARGED, ON HILD BY FEDERAL, STATE FITHER LAN ENFORCEMENT AUTHORITUS FOR ANY VIOLATION OF ANY FAL LAR. STATE LAW COUNTY OR MUNICIPAL LAW REGULATION OR ORDINANCES NOT INCLUTE TRAFFIC VELATIONS FOR WHK'M A FIRE OF STS OR LESS WAS IMPOSTO ALL OTHER CHARGES MUST BE INLLULAD EVEN IF THEY WERE ひなウドDIl your answer to "You," give in liem 13 for each case! (1) approximate date, (2) charge, (3) place, (4) action taken.8. SINCE YOU FILED APPLICATION ALSIA TING IN THIS APPOINTMENT MAVE YOU BEEN BARPEDAY THE US CIVR SERVICE COMMMSKA FROM TAYING EXAMIRAT KURS OR ACCEPTING CIVIL SERVICE APPOINTMENTS!If your answer is "You." give dates of and ressons for such debar ment in liem 12.|     | X   || --- | --- || X   |     || --- | --- |16 (4) MAY YOU EVER FILED A WAIVER OF LIFE INSURANCE COVERAGE UNDER THE FELARAL EMPLOYEES GROUP LIFE INSURANCE ACTI(B) IF YOU HAVE FILED SUCH A WAIVER, HAS IT BEEN CANCELED OR REVOKELI11. SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT: A. MAVE YOU MEN DISCHARGED FROM EMPLOYMENT BECAUSE (1) YOUR CONDUCT WAS NOT SATISFACTORY?(1) YOUR WORK WAS NOT SATISFACTORY?D. HAVE YOU RESIGNED AFTER OFFICIAL NOTIFICATION THAT!(1) YOU'R CONDUCT WAS NOT SATISFACTORY?(YOUR WORK WAS NOT SATISFACTORY?C. MAVE YOU BLER DISCHARGED FROM THE ARMED SERVICES UNDER OTHER THAN HONORABILE CONDITIONS?If your answer to A, B, or C is "Yes." give details in liem 12 as clearly as you can remember, including the nome and address of employer, approximate date, and lessons in each case.|     | X   || --- | --- ||     | X   || --- | --- || X   |     || --- | --- || X   |     || --- | --- || X   |     || --- | --- ||     | X   || --- | --- |12. SPACE FOR DETAILED ANSWERS TO OTHER QUESTICAS (Indicate llem aumbers to which answers apply)| ITEM NO | ITEM NO || ------- | ------- ||         |         ||         |         ||         |         ||         |         ||         |         |INSTRUCTIONS TO ΑΡΡΟΙΝΤΙNG OFFICER. You must determine that this appuintment would be in conformance with the Civil Service Act, applicable Civil Service Mules and Regulations, and arts of Congress pertaining to apimantment. The form should be checked for holding of office, pramon, any recond of serot discharge of arrest, age, chernship, and mem. bers of family Alan, to establish the identity of the appuntes, you should partuularly check (1) his signature and bandenting against the appliration and/or other pertinent papers and (1) his physical appearance against the medical cestini ata.