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# 14-0000024. REFERENCES: List three persons 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 and fitness for the position for which you are applying. Do not repeat names of supervisors listed under Item 16 (EXPERIENCE).| FULL NAME           | PRESENT BUSINESS OR HOME ADDRESS (Give complete current address, including street and number) | BUSINESS OR OCCUPATION       || ------------------- | --------------------------------------------------------------------------------------------- | ---------------------------- || 1. Gordon B. Dunlap | 321 Corona Street, San Antonio, Tex.                                                          | Motion Picture Distributor   || 2. Les R. Blohm     | 903 N. Canal, Carlsbad, New Mexico                                                            | Retired FSO                  || 3. H. B. Gregory    | 1700 Shroyer Road, Dayton, 9, Ohio                                                            | Official, Nat. Cash Register |INDICATE "YES" OR "NO" ANSWER BY PLACING "X" IN PROPER COLUMN25. MAY INQUIRY BE MADE OF YOUR PRESENT EMPLOYER REGARDING YOUR CHARACTER, QUALIFICATIONS, ETC.?|     | YES | NO  || --- | --- | --- ||     | X   |     |INDICATE "YES" OR "NO" ANSWER BY PLACING "X" IN PROPER COLUMN|                                                                                                                                                                                                                                                                                                                                                                              | YES | NO  || ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | --- | --- || 35. ARE YOU AN OFFICIAL OR EMPLOYEE OF ANY STATE, TERRITORY, COUNTY, OR MUNICIPALITY? If your answer is "Yes," give details in Item 39.                                                                                                                                                                                                                                      |     | X   || 36. DOES THE UNITED STATES GOVERNMENT EMPLOY IN A CIVILIAN CAPACITY ANY RELATIVE OF YOURS (BY BLOOD OR MARRIAGE) WITH WHOM YOU LIVE OR HAVE LIVED WITHIN THE PAST 24 MONTHS? If your answer is "Yes," show in Item 39 for EACH such relative: (1) full name, (2) present address, (3) relationship; (4) Department or Agency by which employed; and (5) kind of appointment. |     | X   |26. ARE YOU A CITIZEN OF OR DO YOU OWE ALLEGIANCE TO THE UNITED STATES?|     | X   |     || --- | --- | --- |27. ARE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF THE COMMUNIST PARTY, USA OR ANY COMMUNIST ORGANIZATION?|     |     | X   || --- | --- | --- |SPECIAL INSTRUCTIONS FOR CLAIMING VETERAN PREFERENCEA. If you are claiming preference as a PEACETIME VETERAN who has been awarded a campaign badge or service ribbon, or as a DISABLED VETERAN, or as the WIFE OF A DISABLED VETERAN, or as the WIDOW OF A WAR OR CAMPAIGN VETERAN, attach Veteran Preference Claim, CSC Form 14, together with proof.B. If you are a WARTIME VETERAN not claiming disability preference, you should NOT submit your discharge with this application. Preference will be tentatively credited to you and if appointed, you will be required to submit to the appointing officer, prior to entry on duty, official evidence of separation from active service in the armed forces of the United States in time of war.28. ARE YOU NOW, OR HAVE YOU EVER BEEN A MEMBER OF A FASCIST ORGANIZATION?|     |     | X   || --- | --- | --- |29. ARE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF ANY ORGANIZATION, ASSOCIATION, MOVEMENT, GROUP, OR COMBINATION OF PERSONS WHICH ADVOCATES OR TEACHES THE OVERTHROW OF OUR CONSTITUTIONAL FORM OF GOVERNMENT, OR OF ANY ORGANIZATION, ASSOCIATION, MOVEMENT, GROUP, OR COMBINATION OF PERSONS WHICH HAS ADOPTED A POLICY OF ADVOCATING OR APPROVING THE COMMISSION OF ACTS OF FORCE OR VIOLENCE TO DENY OTHER PERSONS THEIR RIGHTS UNDER THE CONSTITUTION OF THE UNITED STATES OR OF SEEKING TO OVERTHROW OR DEFEAT THE FORM OF GOVERNMENT OF THE UNITED STATES BY UNCONSTITUTIONAL MEANS?|     |     | X   || --- | --- | --- |37. (A) WERE YOU EVER IN THE UNITED STATES MILITARY OR NAVAL SERVICE DURING TIME OF WAR?|     | YES | NO  || --- | --- | --- ||     | X   |     |(B) IS THE WORD "HONORABLE" OR THE WORD "SATISFACTORY" USED IN YOUR DISCHARGE OR SEPARATION PAPERS TO SHOW THE TYPE OF YOUR DISCHARGE OR SEPARATION?(C) WAS SERVICE PERFORMED ON AN ACTIVE FULL TIME BASIS WITH FULL MILITARY PAY AND ALLOWANCES?| (D) DATE OF ENTRY OR ENTRIES INTO SERVICE                       | DATE OF SEPARATION OR SEPARATIONS                                || --------------------------------------------------------------- | ---------------------------------------------------------------- || BRANCH OF SERVICE (Army, Navy, Marine Corps, Coast Guard, etc.) | SERIAL NO. (if none, give grade or rating at time of separation) |If your answer to questions 27, 28, or 29 above is "yes," state in Item 39 the names of all such organizations, associations, movements, groups, or combination of persons and dates of membership. Give complete details of your activities therein and make any explanation you desire regarding your membership or activities therein.38. (A) IF YOU SERVED IN THE UNITED STATES MILITARY OR NAVAL SERVICE DURING PEACETIME ONLY, DID YOU PARTICIPATE IN A CAMPAIGN OR EXPEDITION AND RECEIVE A CAMPAIGN BADGE OR SERVICE RIBBON?|     | YES | NO   || --- | --- | ---- ||     |     | N.A. |(B) ARE YOU A DISABLED VETERAN?|  |   | N.A. |If so, and you have not listed your disability in answer to Item 33, explain in Item 39 below.30. SINCE YOUR 16TH BIRTHDAY, HAVE YOU EVER BEEN ARRESTED, INDICTED, SUMMONED INTO COURT AS A DEFENDANT IN A CRIMINAL PROCEEDING, CONVICTED, FINED, OR IMPRISONED, OR PLACED ON PROBATION OR HAVE YOU EVER BEEN ORDERED TO DEPOSIT BAIL OR COLLATERAL FOR THE VIOLATION OF ANY LAW, POLICE REGULATION OR ORDINANCE (EXCLUDING MINOR TRAFFIC VIOLATIONS FOR WHICH A FINE OR FORFEITURE OF $25 OR LESS WAS IMPOSED)?|     | X   |     || --- | --- | --- |(C) ARE YOU A VETERAN'S WIDOW WHO HAS NOT REMARRIED?|     |     | N.A. || --- | --- | ---- |(D) ARE YOU THE WIFE OF A VETERAN WHO HAS A SERVICE-CONNECTED DISABILITY WHICH DISQUALIFIES HIM FOR CIVIL SERVICE APPOINTMENT?|     |     | N.A. || --- | --- | ---- |THIS SPACE FOR USE OF APPOINTING OFFICER ONLYThe information contained in the answers to Question 37 above has been verified by comparison with the discharge certificate on ________________________________, 19____.Agency: ________________________________________________________ Title:________________________________If your answer is "Yes," list all such cases under Item 39 below. Give in each case (1) the date, (2) the nature of the offense or violation, (3) the name and location of the court, and (4) the penalty imposed, if any, or other disposition of the case. If appointed, your fingerprints will be taken.31. HAVE YOU EVER BEEN DISCHARGED OR FORCED TO RESIGN, FOR MISCONDUCT OR UNSATISFACTORY SERVICE FROM ANY POSITION?|     |     | X   || --- | --- | --- |If your answer is "Yes," give in Item 39 the name and address of employer, date, and reason in each case.32. HAVE YOU EVER BEEN BARRED BY THE U. S. CIVIL SERVICE COMMISSION FROM TAKING EXAMINATIONS OR ACCEPTING CIVIL SERVICE APPOINTMENTS?|     |     | X   || --- | --- | --- |If your answer is "Yes," give dates of and reasons for such debarment in Item 39.33. DO YOU HAVE ANY PHYSICAL HANDICAP, DISEASE, OR OTHER DISABILITY, WHICH SHOULD BE CONSIDERED IN ASSIGNING YOU TO WORK?|     | X   |     || --- | --- | --- |If your answer is "Yes," give complete details in Item 39 so that due consideration can be given to your physical fitness for the job.FILL DETAILED ANSWERS TO OTHER QUESTIONS (indicate item numbers to which answers apply)ITEM NO:ITEM NO:If more space is required, use paper the same size as this page. Write on each sheet your name, address, date of birth, and examination title. Attach to inside of application.Before signing this application check back over it to make sure that you have answered ALL questions correctly.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.False statement on this application is punishable by Law (U. S. Code, Title 18, Section 80).SIGNATURE OF APPLICANT(Sign your name in INK (one given, initial or initials, and surname). If female, prefix Miss or Mrs. and if married, give maiden given name as "Mrs. Mary L. Doe")U. S. GOVERNMENT PRINTING OFFICE 939.9J 16-53940-1