[104-10291-10004.pdf — page 272]
# 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 after appointment. Impersonation is a criminal offense and will be prosecuted accordingly.1. PRESENT ADDRESS (street and number, city and State)3505 Minor Ave. S.E. Washington 19, D.C.2. (A) DATE OF BIRTH (B) PLACE OF BIRTH (city or town and State or country)Feb 20, 1928 Forest River, N. Dak3. (A) IN CASE OF EMERGENCY PLEASE NOTIFY (B) RELATIONSHIP (C) STREET AND NUMBER, CITY AND STATE (D) TELEPHONE NO.Mr. Ross a Hoade Father Forest River, N. Dak4. DOES THE UNITED STATES EMPLOY, IN A CIVILIAN CAPACITY, ANY RELATIVE OF YOURS (EITHER BY BLOOD OR MARRIAGE) WITH WHOM YOU LIVE OR HAVE LIVED WITHIN   THE PAST 12 MONTHS? YES 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) | (1) POSITION (2) TEMPORARY OR NOT (3) DEPARTMENT OR AGENCY IN WHICH EMPLOYED | RELATIONSHIP | MARRIED SINGLE (Check one) || ------------------ | ------------------------------------------------ | ---------------------------------------------------------------------------- | ------------ | -------------------------- || Miss Marilyn Hoade | 3143 W 184st Denver, Col.                        | 1. Clerk 2. temporary                                                        | Sister       | ✓                          |5. ARE YOU A CITIZEN OF OR DO YOU OWE ALLEGIANCE TO THE UNITED STATES? YES NO> X6. ARE YOU AN OFFICIAL OR EMPLOYEE OF ANY STATE, TERRITORY, COUNTY, OR MUNICIPALITY?   If your answer is "Yes", give details in Item 10.> X7. DO YOU RECEIVE ANY 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?   If your answer is "Yes", give in Item 10 season for retirement, that is, age, optional disabling, or by reason of voluntary or involuntary separation after 5 years service; amount of retirement pay, and under what retirement act; and rating, if retired from military or naval service.> X8. SINCE YOU FILED APPLICATION FOR THIS APPOINTMENT HAVE YOU BEEN DISCHARGED, OR FORCED TO RESIGN, FOR MISCONDUCT OR UNSATISFACTORY SERVICE FROM ANY EMPLOYER?   If your answer is "Yes", give in Item 10 the name and address of employer, date and reason in each case.> X9. HAVE YOU EVER ARRESTED (NOT INCLUDING TRAFFIC VIOLATIONS FOR WHICH YOU WERE FINED $5 OR LESS OR FORFEITED COLLATERAL OF $5 OR LESS) SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT?   If your answer is "Yes", list all such cases under Item 10. Give in each case: (1) The date; (2) The nature of the offense or suspicion; (3) the name and address of the court; (4) the penalty imposed, if any or actual disposition of the case. If appointed, your fingerprints will be taken.> X10. SPACE FOR DETAILED ANSWERS TO OTHER QUESTIONS    WRITE IN LEFT COLUMN NUMBERS OF ITEMS TO WHICH DETAILED ANSWERS APPLYINSTRUCTIONS TO APPOINTING OFFICERThe appointing officer before signing the foregoing certificate is made shall determine that applicant is not outside the age limits have been established for the position. It should be in conformance with the Civil Service Act, applicable Civil Service Rules and Regulations and all acts of Congress pertaining to appointment. This form should be checked for posting of office, pension, suitability to ever person with any record of previous dismissal or arrest, and particularly for the following:(1) Identity of appointee – It is the duty of the appointing officer to guard against impersonation and to determine beyond reasonable doubt that the person named appointee was authorized. The appointee’s signature and statement are to be compared with the application before other pertinent papers. If the appointee qualified in a written examination, the signature on this form should be compared with the signature on the examination sheet, which must be opened in the examination room. His photograph and medical certificate may be checked against the medical history for agreement with his previous statements.(2) Age - If definite age limits have been established for the position, it should be determined that applicant is not outside the age range for the appointment, and until such determination is made, the appointment may not be consummated.(3) Citizenship – The appointing officer is responsible for observing the citizenship provisions of (1) the Civil Service Rules and (2) the appropriation acts. Form 61 constitutes satisfactory color for both purposes and is acceptable proof of citizenship status in the absence of conflicting evidence. In doubtful cases the appointment should not be consummated until reassurance has been secured from the certifying office of the Civil Service Commission.(4) Members of Family – Section 9 of the Civil Service Act provides that wherever there are already two or more members of a family serving under continued or permanent appointment in the competitive service, no other member of such family is eligible for probation, or permanent appointment in the competitive service. The appointments of persons entitled to veterans preference are not subject to this requirement. Doubtful cases may be referred to the appropriate office of the Civil Service Commission San document.