[104-10291-10014.pdf — page 176]
# 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. Imperymation is a crumunal offense and will be prosecuted accordingly.1 PRESENT ADDRESS (street and number, city and State)4703 CRESCENT LAW. WESTCHEN CHLE MD2 (A) DATE OF BIRTH (P) PLACE OF BIRTH (city of town and State of country)1 JUNE 1713 FAINERIDGE GEORGIA3 (A) IN CASE OF EVERGLYCY PLEASE NOTIFY (B) RELATIONSHIP (C) STREET AND HUMBI P. CITY AND STATE (2) TELEPHONE NO.UPS BIRTH DONEAL WIFE 4133RECENT COL-C3214 DOES THE UNITED STATES GOVERNMENT EMPLOY, IN A CIVILIAN CAPACITY, ANY RELATIVE OF YOURS (EITHER BY BLOOD OR MARRIAGE) WITH WHOM YOU LIVE OR LIVED WITHIN THE PAST 24 MONTHS? YES NOIf so, for each such relative fill in the blanke below. If additional space is necessary, complate under Item 10.NAME POST OFFICE ADDRESS (1) POSITION (2) TEMPORARY OR NOT (3) DEPARTMENT FOR A WY IN WHICH RELATVAL SHIP SINGLE(Give street number, if any) EMPLOYED (Check one)INDICATE "YES" OR "NO" ANSWER BY PLACING "X" IN PROPER COLUMN10. SPACE FOR DETAILED ANSWERS TO OTHER OLESTIONS| YES | NO  | ITPM NO | WRITE IN LEFT COLUMN NUMBERS OF ITEMS TO WHICH DETAILED ANSWERS APPLY || --- | --- | ------- | --------------------------------------------------------------------- || X   |     |         |                                                                       ||     | X   |         |                                                                       ||     |     |         |                                                                       || X   |     |         |                                                                       ||     |     |         |                                                                       || X   |     |         |                                                                       ||     |     |         |                                                                       || X   |     |         |                                                                       ||     |     |         |                                                                       || X   |     |         |                                                                       ||     |     |         |                                                                       |5. ARE YOU A CITIZEN OF OR DO YOU OWE ALLEGIANCE TO THE UNITED STATES?6. ARE YOU AN OFFICIAL OR EMPLOYLE OF ANY STATE, TLARITORY, COUNTY, OR MUNICIPALITY!......If your answer is "Yos", five details in Item 10.7 DO YOU RECPINT ANY ANNLITY FROM THE UNITED STATES OR DISTRICT OF COLUMBIA GOVERNMENT UNDER ANY RETIME MENT ACT OR ANY PENSION OR OFNER COMPENSATION FOR MILITARY OF NAVAL SERVIC٢٦٠٠٠If your answer is "Yes", give in Item 10 ramson for retirement. that in, age, optional disability, or by reason of voluntary in involuntary separation after 5 ynare' service; amount of retizenment pay, and under what retirement act; and rating of retired from military of naval service.8 SINCE YOU FILED APPLICATIOW RESULTING IN THIS APPOINTMENT HAVE YOU! BEEN DISCHARGED OR FORCED TO RESIGN, FOR MISCONDUCT OR UNSATIS FACTORY SLHVICE FROM ANY POSITIONT.....If your answer is "Yes", fue in Item 10 the name and addre of employer, data and reason in ouch case.9 HAVE YOU DEEN ARRESTED (NOT INCLUDING TRAFFIC VAYMATIONS FOR WHICH YOU WERE FINED OR LESS, OR FORFFEFLOOR LATERAL OF 123 OR LESS) SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT?If your answer is "Yes", list all such cases under Item 10. Give in Dash case (1) The date, (2) the nature of the offense et volation, (3) the name and location of the court. (d) the penalty imposed, if any, or other dispontion of the саво. It appointed, your Angerprints will be taken.INSTRUCTIONS TO APPOINTING OFFICERThe appointing officer before whom the foregoing certificate is inade shall determine to his own satisfaction that this appointment wilt te in conformace with the Civil Service Act, apple able Civil Service Rules and Regulations and aits of Congress pertaining to appointinent,This forrn should be checked for holding of ofice, pension, suitability in con- tation with any record of recent discharge or arrest, and particularly for the filowing:(1) Identity of appointos-It is the duty of the appointing officer to and agnnst inpersonation and to deteanine beyond reasonable doubt that the intee ta the same person whose appement was authorized The antee's signature and handwriting are to be coap red with the application adde other pertinent papers, If the appmuntre qual.hot in a written exami naiwn, the signature on this form should be compred with tac signature un the declaration shret, which was signed in the front. Ha physs. al wance may be checked aga ust the snedual certihate. The appointee nay also be questioned on his personal history for agreement with the previo Katements(2) Age -If definite uge limits have been established for the groeition, it should be determined that applicant is not outside the age entice for Antment. Until such de termination is made, the appointment may VA be cose womated.(5) Citizenship -The appointing other is responsible for observing the eitizenship provisions of (1) the Civil Service Rules and (2) Form of constitutes on altidavit for with purьнага вай 18 the proof of citizensnip status in the alaence of condisting evidence, la coceful cases the appointment should not be consummated until clearance has been saured from the certifying othee of the Civil Servue Carmmsalon,(4) Mothers of Family -Section 9 of the Civil Service Art provides that whenever there are already two or more members of a fer. y urving under probational or permanent appointment in the compl۱۲۷r, no other member of sul family in cig ble for probationele permintment in the competitive areviCE The appuntaments of peracta erth to veteran preference are not subject to this requirerent The memfariston does not apply to tempat n'ments Doubtful rooms they refused to the appropriate othee of the Service Couumas.standing PRINTING OFFICE