[104-10291-10014.pdf — page 205]
23. Relative(s) (List the person(s) living in the United States or Territories of the United States who are NOT related to you and who have definite knowledge of your qualifications. Do not repeat names of supervisors or references. Do not repeat a name appearing in item 18, 19, or 22. Attach to insideFULL NAME BUSINESS OR HOME ADDRESS BUSINESS OR OCCUPATION(Give complete address including street and number. )1. 2. 3. 24. May inquiry be made of your present employer regarding your character qualifications etc.?    Indicate "Yes" or "No" answer by placing X in proper column.    YES NO25. Are you a citizen of the United States?26. Do you advocate, or have you ever advocated, or are you now    a member of any organization that advocates the overthrow of the Government of the United States by force or violence?If your answer is "Yes," give complete details in Item 38.27. Within the past 12 months, have you habitually used intoxicat-ing beverages to excess?28. Since your 16th birthday have you ever been convicted or fined, or imprisoned, or placed on probation, or have you ever been ordered to forfeit bail, for the violation of any law, (including ordinary traffic violations for which a fine of $25 or less was imposed)?If your answer is "Yes", list all such cases under Item 38 be-low. Give in item 38: (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. If appearing in court, your fingerprints will be taken.29. Have you ever been discharged or forced to resign for mis-conduct or unsatisfactory service from any position?If your answer is "Yes", give in Item 38 the name and address of employer at the time and reason in each case.30. Do you receive an annuity from the U. S. or D. C. Government under any retirement act or any pension or other compensation for military or naval service?If your answer is "Yes", give in Item 38 reason for retirement i.e. non-optional disability or by reason of voluntary or in- voluntary separation after 5 years service, amount of retirement pay, and under what act retired, and rating if retired from military or naval service.31. Are you an official or employee of any State, Territory, county or municipality?If your answer is "Yes," give details in Item 38.32. Does the U. S. Government employ in a civilian capacity any relative of your own (by blood or marriage) with whom you live or have lived within the past 6 months?If your answer is "Yes," show in Item 38 for EACH such rela- tive: (1) full name; (2) present address; (3) relationship; (4) department or agency by whom employed; and (5) kind of appoint- ment.33. Have you ever had a nervous breakdown?If your answer is "Yes," give complete details in Item 38.34. Have you ever had tuberculosis?If your answer is "Yes," give complete details in Item 38.35. Have you any physical defect or disease whatsoever?    If your answer is "Yes," give complete details in Item 38.36. (a) Were you ever in the United States Military or Naval Service during time of "A War?"(b) Is the word "honorably" or the equivalent word used in your discharge or separation?(c) What character (honorable etc.) was given you?(d) What service (combat, technical, etc.) was performed with full military pay and allowances?Date of entry or entries into serv-ice. Date of expiration or separa-tion.Branch of service, give grade or rating at (Army, Navy, M. C. time of separation.C. G., etc.).IF YOUR ANSWERS TO THIS QUESTION INDICATE THAT YOU ARE ENTITLED TO VETERAN PREFERENCE, THIS APPLICATION WILL BE CONSIDERED INAPPLICABLE IF APPOINTMENT IS MADE WITHOUT GIVING VETERAN PREFERENCE ATTACH TO THIS APPLICATION, OFFICAL EVIDENCE OF MILITARY OR NAVAL SERVICE FOR LATEST PERIOD OF ACTIVE DUTY IN THE ARMED FORCES OF THE UNITED STATES DURING TIME OF WAR. DO NOT SUBMIT RECORD OF DISCHARGE OR SEPARATION WITH THIS APPLICATION.Indicate "Yes" or "No" answer by placing X in proper column. YES NO37. (a) If you served in the U. S. Military or Naval Service dur-ing peacetime ONLY, did you participate in a com-paign or expedition and receive a campaign service ribbon?(b) Are you a disabled veteran?(c) Are you the unmarried widow of a veteran?(d) Are you the wife of a veteran, whose service-con-nected disability?IF YOUR ANSWER TO QUESTION 37 (b), (c) OR (d) IS "YES" AND YOU WISH TO CLAIM VETERAN PREFERENCE, ATTACH TO THIS APPLICATION VETERAN’S PREFERENCE CLAIM (G. S. C. S. COMMISSION FORM 14) TOGETHER WITH THE NECESSARY PROOF SPECIFIED THEREIN.THIS SPACE FOR USE OF APPOINTING OFFICE ONLYThe information contained in the answers to Question 16 above has been veri-fied by comparison with the discharge certificates on ....38. Specify in full detail answers to other questions (indicate item numbers to which answers apply).    Item No. AgencyIf more space is required, use paper the same size as this page. Write on each sheet your name, address, date of birth, and organization title. Attach to inside of this application.FALSE STATEMENT ON THIS APPLICATION IS PUNISHABLE BY LAW (U. S. CODE TITLE 18, SECTION 1001).I certify that the statements made by me in this application are true, complete, and correct to the best of my knowledge and belief and are made in good faith.DateSignature of applicant. Il female, prefix Miss or Mrs. (Given name in full) MissGPO —18—67250-1