[104-10291-10014.pdf — page 180]
# DECLARATION OF APPOINTEEThis form is to be completed before entrance on duty. Question 3 is to be answered in all cases, otherwise answer only those questions which require an answer different from that given to the corresponding questions on your application form. Il no answers are different, write "NONE" in Item 10, below. Any false statement in this declaration will be grounds for cancellation of application or dismissal after appointment. Impersonation is a criminal offense arvl will be prosecuted accordingly.1. FRISINT ADDRESS (street and number, city and State)4703 CRESCENT SIN.W. WASHINGICH D.C.2. (A) DATE OF BIRTHJUNE 1913(1)MACE:TH (city of town and State or country)LAIN BRIDG GEORGIA3. (A) IN CASE OF EMERGENCY PLEASE NOTIFY(M) PELATIONSHIP (C) STREET AND NUMBER CITY AND STATEMAs. BIRCH D. NEAL WIFE 4703 CRESCENT NOW. WASHINGTON D.C.(2) TELEPHONE RO. 06-03214. DOES THE UNITED STATES GOVERNMENT EMPLOY, IN A CIVILIAN CAPAMATY, ANY PILATIVE CAN YOURS (FATHER BY BLOCO OR MARRIAGE WITH WHOM YOU LIVE OR HAVE LIVED WITHIS THE PAST 24 MONTHS?YES [ ] NO [X]If so, for each such relative fill in the blanks belere. It additional space is necessary, complete under Item 10.| NAME | WAT(One street number, if any) | () POSITION (1) TLAN WI() DEPARTMENT IN WHIСи EMPUSED | RELATIONSHIP | MA SINGLED| FOU (Check one) |     |     |     |     || --------------- | --- | --- | --- | --- || 1.              | ... | ... | ... | ... || 2.              | ... | ... | ... | ... || 3.              | ... | ... | ... | ... || 4.              | ... | ... | ... | ... || 5.              | ... | ... | ... | ... |INDICATE "YES" OR "NO" ANSWER BY PLACING "X" IN PROPER COLUMN|                                                                                                                                                                                                                                                                                                                                                 | YES | NO  || ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | :-: | :-: || 5. ARE YOU A CITIZEN OF OR DO YOU OWE ALLEGIANCE TO THE UNITED STATEST..                                                                                                                                                                                                                                                                        |  X  |     || 6. ARE YOU AN OFFICIAL OR EMPLOYEE OF ANY STATE, TERRITORY, COUNTY, OR MUNICIPALITY?......                                                                                                                                                                                                                                                      |     |  X  || *If your answer is "Yes", give detaile in Item 10.*                                                                                                                                                                                                                                                                                             |     |     || 7. DO YOU RECEIVE ANY ANNUITY FROM THE UNITED STATES OR DISTRET OF COLUMBIA GOVERNMENT UNDER ANY RETINI MENT ACT OR ANY PUMA OR OTHER COMPENSATION FOR MILITARY OR NAVAL LI AVICRI........                                                                                                                                                      |  X  |     || *Il your answer in "Yes", five in Items 10 reason for retirement, that is, age, optional disability, or by rearun of voluntary or involuntary separation after 5 youta auricunt A retirement pay, and under what retirement act; and rating, if retired from nulitary or naval service*                                                         |     |     || 8. HAVE YOU EVER BEEN DISCHARGED, OR FORCED TO RISION, FOR MIBOUCT OR UNSATISFACTORY SINVICE FROM ANY POSITIONT...                                                                                                                                                                                                                              |  X  |     || *If your answer is "Yes", dive in Item 10 the name and address of employer, date, and reason in oach олно.*                                                                                                                                                                                                                                     |     |     || 9. SINCE YOUR ISTH DIRTHDAY, HAVE YOU EVER BEEN ARRESTED IDENTED OR SUMMONED INTO COURT AS A OFFENDANT IN A CRIMINAL P CONVICTED FINED, OR IMPRIVIND OR PLALEDON PROBATHIN EVER BEINOHDI RED TO DEMIT BAIL OR COLLATERAL FOOT A OF ANY LAW POLICE REGULATION ORORDNANCE (1XCLUDING MAS VIOLATIONS FOR WHICH A FINE OR FORFEITURL OF $250RLYFASI |  X  |     || *If your answer is "Yes", lhat all auch cases under Item 10. Give in ensch case (1) The data, (2) the nature of the Manse or violation; (3) the name and location of the court; (4) th penalty imposed, if any, or other disposition of the case. appointed, your Angerprints will be taken.*                                                   |     |     |10. SPACE FOR DETAILED ANSWERS TO OTHER QUESTIONSITEM WHITE IN LIFT (CALUMNUMBERS OF ITEMS TO WHICH LETARET ANTWERE SOLiINSTRUCTIONS TO APPOINTING OFFICERThe appointing officer before whom the foregring cartsfrute is made shall determine to his own satisfaction that this appointinent wradd te in cunturmane with the Civil Service Art, applicable Civil Service Kuled requirtsons and acts of Congress pertaining to appointment.This foun should be checked for holding of office, pensiun, suitability in con nection with any record of recent duscharge of arrest, and particularly for the following:(1) Identity of appointes. The appointee's signature soul handwriting are to be compared with the application and/or other pertah papers. The phystal appeaгance may be checked against the macool certificate. The appaantee may also be questioned on this personal history his agreement with his previous statements.(2) Ago -lf definite age limits have been establishert fe the position, it should be determined that applicant is pot outside the age range baappantment, Until such determination is made, the appointment may not be consuaumated.(3) Citizenship The opprinting officer is resproceuble for observing the citizenslap provisions of (1) the Civil Service Mulre and (1) appropiative 1. Constitutes an affet for boats gustard 10 septable pre consensup status in the stacore of conflirting evidenir. In duubiful care ament should med timeuminated will clearance has been seruwed tsum the certifying office of the Civil Service Commisawan,(4) Members of Family-Bection 9 of the Civil Servire Art provides thee whatever there are already two moxe anembers A fermily serving امریانی or permanent appeantment in the crampetitive servue, no uebler of such family is eligible for probetual permanent protein the competitive service. The apprantnents of perus entitled to veterum preterenie are not subjert to this requirement. The members-ed-fastuly proviawa drs we apply to temporary Beats. Druthful cases may be referred is the appropriate office of the Civil Service Communion for decimon.