[104-10291-10000.pdf — page 252]
# 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)4520 Mac Arthur Blud. WASH., D. C.(A) DATE OF BIRTH:OCT 9, 19283. (A) IN CASE OF EMERGENCY PLEASE NOTIFYJULIAN FOX(B) PLACE OF BIRTH (city or town and State of country)BROOKLYN, NY(B) RELATIONSHIPBrother(C) STREET AND NUMBER, CITY AND STATE340.E. 53 St. New York N.Y.(D) TELEPHONE NO.EL-5-78294. 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 24 MONTHS?If 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) || ---- | ------------------------------------------------ | ---------------------------------------------------------------------------- | ------------ | -------------------------- ||      |                                                  |                                                                              |              |                            ||      |                                                  |                                                                              |              |                            ||      |                                                  |                                                                              |              |                            ||      |                                                  |                                                                              |              |                            ||      |                                                  |                                                                              |              |                            ||      |                                                  |                                                                              |              |                            ||      |                                                  |                                                                              |              |                            |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 STATES?                                                                                                                                                                                                                         | X   |     || 6. ARE YOU AN OFFICIAL OR EMPLOYEE OF ANY STATE, TERRITORY, COUNTY, OR MUNICIPALITY?                                                                                                                                                                                                           |     | X   || If your answer is "Yes", give details in Item 10.                                                                                                                                                                                                                                              |     |     || 7. DO YOU RECEIVE ANY ANNUITY FROM THE UNITED STATES OR DISTRICT OF COLUMBIA GOVERNMENT UNDER ANY RETIREMENT ACT, PENSION OR OTHER COMPENSATION FOR MILITARY OR NAVAL SERVICE?                                                                                                                 |     | X   || If your answer is "Yes", state (1) reason for retirement, what is age, optional disability, or for reason of voluntary or involuntary separation after 5 years service; amount of retirement pay, and under what retirement act; and, if retired from military or naval service.               |     |     || 8. SINCE YOU FILED APPLICATION DESCRIBED IN THE APPENDIX HERETO, HAVE YOU BEEN CONVICTED OR FORCED TO RESIGN FOR MISCONDUCT OR UNSATISFACTORY SERVICE FROM ANY POSITION?                                                                                                                       |     | X   || 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 (NOT INCLUDING TRAFFIC VIOLATIONS) FOR ANY REASON WHATSOEVER (LESS THAN $25.00 OR MISDEMEANOR COLLATERAL OF $25.00 OR MORE) OR HAVE YOU HAD APPLICATION REJECTED IN THIS APPOINTMENT?                                                                                |     | X   || 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 violation (3) the name and location of the court (4) the penalty imposed, if any, or other disposition of the case. If appointed, your fingerprints will be taken. |     |     |10. SPACE FOR DETAILED ANSWERS TO OTHER QUESTIONSWRITE IN LEFT COLUMN NUMBERS OF ITEMS TO WHICH DETAILED ANSWERS APPLYINSTRUCTIONS TO APPOINTING OFFICERThe appointing officer before whom the foregoing certificate is made shall determine to his own satisfaction that the appointee is or would be withoutCitizenship proof (1) the Civil Service Rules and Regulations andForm 14 constitutes to afford the facts personal interviewcitizenship status in the absence of conflicting evidenceappointment should be immediately canceledthe Civil Service Operations(1) Identity of appointee. It is the duty of the appointee togeneral appearance and to determine that said appointee isappointee is the same person who signedappointee's signature and handwriting should be compared with thesimilar plications papers If the appointee questioned in ashould be compared with thethe declaration strict, which was failed in thesimilarity also be determined also not be referred tothe Civil Service Commisionel for decision.