[104-10225-10003.pdf — page 399]
# DECLARATION OF APPOINTEEThis form is to be completed before entrance on duty. Answer all questions. Any false st. declaration will be grounds for cancellation of application or dismissal after appointment. Impe vent in this criminal offense and will be prosecuted accordingly. ation is a1.  PRY INT ADDRESS (street and number, city and State)16 - A LARE STA  CAPE FLA2 (A) DATE OF BIRTH (B) PLACE OF BIRTH (city of town and State of country)12 -8-35 YONKER  NEW YORK3 (A) IN CASE OF EMERGENCY PLEASE KUTIFY (B) RELATIONSHIP (C) STREET AND NUMBER CITY AND STATE (D) TELEPHONE RO.MS J Piccolo FATHER 1676 LARE STA --- 714--666--5554 ---4. DOES THE UNITED STATES GOVERNMENT EMPLOY, IN A CIVILIAN CAPACITY, ANY RELATIVE OF YOURS (LITHER BY BLOOD OR MARRIAGE WITH WHOM YOU LIVE OR HATE LINED WITHIN THE PAST 24 MONTIS! YES [X] NOIf so, for each such relative fill in the blanks below If additional space is necessary, complete under Item 10.| NAME | POST OFFICE ADDRESS (Give street number, if any) | POSITION (c) TEMPORARY OR WIT DEPARTMENT OR AGENCY IN WHICH EMPLOYED | RELATIONSHIP | MARRIED | SINGLE (Check one) || ---- | ------------------------------------------------ | -------------------------------------------------------------------- | ------------ | ------- | ------------------ ||      |                                                  |                                                                      |              |         |                    ||      |                                                  |                                                                      |              |         |                    ||      |                                                  |                                                                      |              |         |                    ||      |                                                  |                                                                      |              |         |                    ||      |                                                  |                                                                      |              |         |                    |INDICATE "YES" OR "NO" ANSWER BY PLACING "X" IN PROPER COLUMN10. SPACE FOR DETAILED ANSWERS TO OTHER QUESTIONS|                                                                                                                                                                                                                                                                                            | YES | NO  | ITEM NO. | WRITE IN LOT 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 RECTIVE ANY ANNUITY FROM THE UNITED STATES OR DISTRICT OF COLUMBIA GOVERNMENT UNTER ANY PITH MENE ACT OR ANY PENSION CAR OTHER COMPENSATION FOR MILITARY OR NAVAL LAVICE?                                                                                                        |     | X   |          |                                                                      || If your answer to You", give in Item 10 reason for retirement, that is, age, optional disability, or by reason of voluntary of involuntary separatus alrer 5 years' service; amount of retirement par, and under what retirement act, and rating it retired from military of naval service |     |     |          |                                                                      || 8. SINCE YOU FILED APPLICATION RESIA TING IN THIS APPOINTMENT HAVE YOU BLEN DISCHARGED OR FORCED TO PIGN, FOR MISCONCT OF LIGA FIS FACTORY SERVICE FROM ARS POSITION?                                                                                                                      |     | X   |          |                                                                      || If your answer is "Yes", Live in Item 10 the name and address of employer, date and reason in each case                                                                                                                                                                                    |     |     |          |                                                                      || 9. HAVE YOU BETH ARRESTED (NOT INCLUTUNG TRAFFIC VMRATIONS POR WHICH YO WIRE FINED OR LESS OR FURIPITE OCTALATERAL INF LASS) SINCE YOU FILLO AS PLICAFRAS RESULTING IN THIS APPANIMENT                                                                                                     |     | X   |          |                                                                      || If your answer is "Yes", list all such cases under Item 10. Give in each case: (1) The date, (1) the nature of the offence of violation (3) the name and location of the court (6) the penalty inwand of any of other disposition of the case If appointed, your Angueprints will be taken |     |     |          |                                                                      |INSTRUCTIONS TO APPOINTING OFFICERThe appointing niftree hefive whom the foregoing certificate le mote shall Merinice tu brevem ser that this appointment must be un with the Civil Bintungenanimeni, The Sarned te hebat he hiding the presina sutin the hear mind of sarat diharge of real partem alesiy far the(1) Identity of appointeet the duty of the non 10 pad galteriyant promised(1)definite age Baits have been estabishat for the he determined thetandis 2.4 msit the age range is . Umestery want the waters way out berm(3)Thamnable he sharin ipad (1) the lowe Hoe alle(Mammers w Po the storm aliafting combre ۱۸minid the Cird Barve A. thel thewing who of them. wasse has been wo that the Thethe Anledning i gamot ng paroze cad erg on powe Thaoith the gestr