[104-10291-10002.pdf — page 224]
# 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. FRESENT ACCRESS (street and number, city and State)Great Heights #512 Tokye Japan / DRS, HI, FEC2. (A) DATE OF BIRTH (8) PLACE OF BIRTH (city or town and State of country)4 October 1915 Fitzgerald. Georgia3. (A) IN CASE OF EMERGENCY PLEASE NOTIFY (B) RELATIONSHIP (C) STREET AND RUMBER, CITY AND STATE (0) TELEPHONE NOAdelia Callaway Wheeler wife DRS, HA, FEC 865303HPE 5004. COES THE UNITED STATES GOVERNMENT EMPLOY, IN A CIVILIAN CAPACITY, ANY RELATIVE OF YOURS (LITHZA DY BLOOD OR MARRIAGE) WITH WHOM YOU LIVE OR HAVE LIVED IN THE PAST 24 MONTHS YES NOIf so, for each such relative fill in the blanke below. If additional space is necessary, complete under Item 10.| NAME | POST OFFICE ADDRESS (Oive street number, if any) | (1) POSITION (1) TEMPORARY OR NOT (3) DEPARTMENT OR AGENCY IN WHICH EMPLOYED | RELATIONSHIP | MARRIED SINGLE (Check one) || ---- | ------------------------------------------------ | ---------------------------------------------------------------------------- | ------------ | -------------------------- || 1.   |                                                  |                                                                              |              |                            || 2.   |                                                  |                                                                              |              |                            || 3.   |                                                  |                                                                              |              |                            || 1.   |                                                  |                                                                              |              |                            || 2.   |                                                  |                                                                              |              |                            || 1.   |                                                  |                                                                              |              |                            || 2.   |                                                  |                                                                              |              |                            |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 STATES                                                                                                                                                                                                                                                                                                                                                                                                         | X   |     || 6. ARE YOU AN OFFICIAL OR EMPLOYER OF ANY STATE, TERRITORY, COUNTY. OR MUNICIPALITY!... If your answer is "Yes", Nien details in Itam 10.                                                                                                                                                                                                                                                                                                                                     |     | X   || 7. DO WYJ RECEIVE ANY ANNUITY FROM THE UMILD STATES OF DISTRICT OF COLUMBI GOVERNMENT UNDEN ANY PETIDE PEJAT ACT OR ANY PENSION OR OTHER COMPENSATION FOR MILITARY OF RAVAL SEFTICE If your answer is Yes". Aiva in liom 10 recton for rolirement that 9. a, optional disability, or by season-of voluntary or involuntary separation altor 5 years' servion; atqunt of retirement pay, and under what retirement act; and rating.. if rotired from anhtary of naval service. | X   |     || 8. SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT HAVE YOU BEEN DISCHARGED, OR FORCED TO ASSIGN, FOR MISCONDUCT OR UNSATI FACTORT SERVICE FROM ANY SOSITION.... Hyour an give in Itou 13 the name and udidrass of employer, riaco and reason in each ones.                                                                                                                                                                                                         |     | X   || 9. HAVE YOU EZEN ARRESTED (NOY MACLUDING TRAFFIC VIOLATIONS FOR WHICH YOU WERE FIRES OR LESSON FORESTED COLLATERAL OF OR LESS) SINCE YOU FILED APPLICATION GATING IN This APFONTUENTI.. Il your answer is "Yes", ist all auch parcs under Item 10. Erre in cash caso: (1) Tho date: (2) cho nature of t penalt tion; (3) the name and location of the court (4) the  nimited, if any, or other disation of the case. / appointed, your fingerprints will be trien.            |     | X   |10. SPACE FOR DETAILED ANSWERS TO OTHER QUESTIONSWRITE IN LEFT COLUMN NUMBERS OF ITEMS TO MUCH DETAILED ANSWERS APPLYINSTRUCTIONS TO APPOINTING OFFICERThe candading then the foregoing criticate la mata de determine to במט וולtisfaction that this pretental www bei wale with the Cool Serence Act, spolwante Citi bervice Rules and Rezid Octa of Congress portaiang to op 1a formal be cho bat for bulling of oare, pension, suitabilty in cos- nection will say record of terens discharge or ami awal patcularly for the folloning: (1) Identity of appuintre-l la the duty of the appdalay guard against sonra leyoulove that ices the same mat 44 entirsentasean adaritingaruparalith the epphra suphrnced, Bulke other ן זמןapers, if the appointee quibe in a w natica, the venture co the tom hd be compel with the the de Iration was the leat sto natal yuusut the metal cortice. The Tay tlso be questical fractal is has рутиная Age - definite age limits have been reblant for the position it shackl that appeant nut outside the ese reize fa appointment Hasiera delade hent است ادت tい! 13) Canahin hanting oilser is eerbie forving the 1) פורים( the Civil Service Rules and appropriate Formandant for both purposes pat is merkable of CLOtatus in the abernes of onlisting evocre in domacul caves the be contustele has wrured ЧА Οι core of the Civil fense Comにな (1) Part of the Cool Servant provitice that こけし are alroad/ two or mors is falmler pernent in the yes, no other tire were The apperatorate of state to veteraa best to thit requir Stay wipanciments. Die rulestad ta