[104-10291-10001.pdf — page 254]
# 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 atter appointment. Impersonation la a criminal offense and will be prosecuted accordingly.1. PRESENT ADDRESS (street and number, city and State)3073 So Woodrow St. Arlington, Va2. (A) DATE OF BIRTH (B) PLACE OF BIRTH (city or town and State of country)16/6/21 Harrisburg, Pa3. (A) IN CASE OF EMERGENCY PLEASE NOTIFY: (B) RELATIONSHIP (C) STREET AND NUMBER, CITY AND STATE (D) TELEPHONE NOJeanne H. Smith Wife 3073, So Woodrow St.ARLINGTON, VA.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 3 YEARS?If so, for each such relative fill in the blanks below. If additional space is necessary, complete under Item 10.NAME POST OFFICE ADDRESS (1) POSITION (2) IF TEMPORARY OR NOT RELATION- (3) DEPARTMENT OR AGENCY IN WHICH SINGLE SHIP EMPLOYED (Check one)INDICATE "YES" OR "NO" ANSWER BY PLACING "X" IN PROPER COLUMN5. ARE YOU A CITIZEN OF OR DO YOU OWE ALLEGIANCE TO THE UNITED STATES? [X] YES NO6. ARE YOU AN OFFICIAL OR EMPLOYEE OF ANY STATE, TERRITORY, COUNTY, OR MUNICIPALITY?If your answer is "Yes", give details in Item 10.7. DO YOU RECEIVE AN ANNUITY FROM THE UNITED STATES OR DISTRICT OF COLUMBIA UNDER ANY PRESENT OR FUTURE RETIREMENT ACT OR ANY PENSION OR OTHER CONSIDERATION 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 or involuntary separation after at least 3 years service; amount of retirement pay, endowment or like retirement act; and rating, if retired from military or naval service.8. HAVE YOU FILED APPLICATION PREPARATORY TO ENTRANCE INTO THIS APPOINTMENT, OR DISCHARGE FROM UNDESIRABLE FEATURES OF MILITARY SERVICE FROM ANY POSITION?If your answer is "Yes", give in Item 10 the name and address of employer, date and reason in each case.9. HAVE YOU BEEN ARRESTED (INCLUDING TRAFFIC VIOLATIONS) FOR ANY OFFENSE(S) FOR WHICH YOU WERE CHARGED WITH A VIOLATION OF THE LAW (INCLUDING ALL OFFENSES FOR WHICH FORFEITURE OF COLLATERAL OR SIMILAR ACTION RESULTED IN APPOINTMENT, YOUR FINGERPRINTS WILL BE TAKEN).If your answer is "Yes", give all cases under Item 10. Give in each case: (1) The date, (2) the nature of the offense or violation. (3) The name and location of the court, (4) the penalty imposed, if any, or other disposition of the case.10. SPACE FOR DETAILED ANSWERS TO OTHER QUESTIONSWRITE IN LEFT COLUMN NUMBERS OF ITEMS TO WHICH DETAILED ANSWERS APPLYINSTRUCTIONS TO APPOINTING OFFICER(1) The appointing officer before submitting forms to Washington should be certain to make clear to the appointee that any statement made will be regarded as a solemn declaration and that appointee should take care to answer fully all questions. The appointing officer should carry these instructions to the appointee.This form should be checked by appointing officer, before submission, to ascertain that every question is answered fully and accurately for the information of the Civil Service Commission.(2) Penalties of appointees refusing to take the duty of the appointing officer in that regard, agreements in advance to real treasurers will not stampede as the census police back appointment and will mark appointee's sagacity and laboriousness are to be computed with the appointee also will mark them. The appointee is directed in writing, also the appointee who takes instead by several, the appointee will also mark them. Also, the appointee will check them again in the appointment of police, so the appointee says to charted region the contest arose. The regulation of the census police takes be required will be required with be certain to.(3) Age-skill details are limits have been established for. The question should be determined that applicant is to ascertain the age limits. Until such determination is made, the appointee will not be put into position.(4) Instructions The appointing officer is responsible for obtaining proper credentials. The Civil Service Index and (2) Form 91 if appointee will affidavit for before permanent and in intermittent status, in the absence of conducting an election. In appointing should not be commencement and clearances and to the certifying office of the Civil Service Commission.(5) Members of Family Section 9 of the Civil Service Act provides that "where there are already two or more members of a family in the public service, preference in examinations or appointments shall not hereafter be given to other members of such family and that is no reason should the preference for appointees of veterans referred to in existing statutes is permitted. The members of family in permitting shall not apply to the re-appointment when be required to the the appointee shall and is Civil Service Commission for determination.