[104-10291-10000.pdf — page 255]
# STATEMENT OF PRIOR FEDERAL AND MILITARY SERVICEIMPORTANT: The information on this form will be used in determining creditable service for leave purposes and retention credits for reduction in force. The employee should complete Part I and the Personnel Office should complete Parts II through IV.## PART I-EMPLOYEE'S STATEMENT1. NAME (Last, first, middle initial)Fox, Jerome2. DATE OF BIRTH9 Oct. 19283. LIST THE FOLLOWING INFORMATION CONCERNING ALL FEDERAL AND DISTRICT OF COLUMBIA SERVICE YOU HAVE HAD PRIOR TO YOUR PRESENT APPOINTMENTS (Do not include military service.)| NAME AND LOCATION OF AGENCY | FROM |       |     | TO   |       |     | TYPE OF APPOINTMENT IF KNOWN || --------------------------- | ---- | :---: | :-: | ---- | :---: | :-: | ---------------------------- ||                             | YEAR | MONTH | DAY | YEAR | MONTH | DAY |                              || CIA                         | 59   |   6   | 15  | 59   |   6   | 15  |                              |PART II-THIS COLUMN IS FOR PERSONNEL OFFICE USE9. RETENTION GROUP10. CSC STATUS (For permanent employees only).YES NO11. SERVICE    YEAR MONTH DAY4. LIST PERIODS OF SERVICE IN ANY BRANCH OF THE ARMED FORCES OF THE UNITED STATES. IF YOU HAD NO MILITARY SERVICE, WRITE "NONE"| BRANCH   | FROM |       |     | TO   |       |     | DISCHARGE (Hon. or dishon.?) || -------- | ---- | :---: | :-: | ---- | :---: | :-: | ---------------------------- ||          | YEAR | MONTH | DAY | YEAR | MONTH | DAY |                              || U.S.ARMY | 1952 |  NOV  | 17  | 1954 |  NOV  | 16  | HON.                         |5. DURING PERIODS OF EMPLOYMENT SHOWN IN ITEM 3. DID YOU HAVE A TOTAL OF MORE THAN 6 MONTHS ABSENCE, WITHOUT PAY INCLUDING PERIODS OF MERCHANT MARINE SERVICE, DURING ANY ONE CALENDAR YEAR? YES [X] NOIF ANSWER IS "YES" LIST FOLLOWING INFORMATION.| TYPE IF KNOWN (LWOP, Furl., Susp., AWOL, Mar., Mar.) | FROM |       |     | TO   |       |     | TOTAL             || ---------------------------------------------------- | ---- | :---: | :-: | ---- | :---: | :-: | ----------------- ||                                                      | YEAR | MONTH | DAY | YEAR | MONTH | DAY | YEARS MONTHS DAYS |2 0 01 2912. TOTAL SERVICE1 2913. NONCREDITABLE SERVICE (Leave purposes only):14. NONCREDITABLE SERVICE (RIF purposes only):6. DURING THE FEDERAL SERVICE LISTED IN ITEM 3 DID YOU ACQUIRE A PERMANENT COMPETITIVE CIVIL SERVICE STATUS?YES NO(If answer is "Yes," in what agency were you employed at the time status was acquired?).15. REEMPLOYMENT RIGHTS    YES NO7. ARE YOU:A. THE WIFE OF A DISABLED VETERAN? YES NOB. THE MOTHER OF A DECEASED OR DISABLED VETERAN? YES NOC. THE UNREMARRIED WIDOW OF A VETERAN? YES NO16. RETENTION RIGHTS    YES NO17. EXPIRATION DATE OF RETENTION RIGHTS8. TO BE EXECUTED BEFORE A NOTARY PUBLIC OR OTHER PERSONS AUTHORIZED TO ADMINISTER OATHS.I swear (or affirm) that the above statements are true to the best of my knowledge and belief.15 June 1955(DATE)Jerome Fox(SIGNATURE)Subscribed and sworn to before me on this 15th day of June 1955 at Washington, D.C.(MONTH) (CITY) (STATE)[seal] Collins ... Higgins...NOTE: If oath is taken before a Notary Public, the date of expiration of his Commission should be shown.(OVER)