~ DECLARATION OF APPOINTEE This form is to be completed before entrance on duty. Quessien 3 fs fo be answered in all cases, otherwiso answer oniy those questions which requiroan answer diderent from that fiven to the corresporncing questions on yourapolivation form, If no answers sre diterent, write “NONE in ftom 10, below. Asay false statement in this declaration will be grounds for canceilation of upplication or dismissal after appointment. Impersonation is a criminal offense end will be prosecuted nowonlingly. 4, PRESENT AQUSS (etree? and nuittber, ory and State} : 9200 1618 St AM, Wasitive Tow OC. (Arr 319) ae a Gh a A LYE a ene ee & (a) DATE Ce BAI (5) PLACE OF DIATH (city ce town and State oe counter) | 1 PEC ITT Stocw red Mass 4. (AD IN CASE OF ENTRGLACY PLEASE NOT Y. | rem a Been row CC} STRAT AND NUMBER, CITY AND STATE Tn RI LATIONS INP A A ASG aera ParNeR | 21S BELrtewr Ave, a _t. Racoon ren, flass. | VVO2 -ts 4& OOS TRE UNITED STATES GTR eEST EMPLOY, OW A CIVILIAN CAPACITY, ANY RELATIVE OF WAUSS QOISER BY BLOOD o@ SMARRIAGI) WITH WHOM ON) LIVE Oi HAVE UVES BITES fe? ND . LA . + nthe blanks dslow. Uf adiditeenal spaca ie mevessary, sumptete under Hon 10, 1 ———" Pf OUROSITON (3) PPMnitany OR BOT Tee rast se xontnsr [7] yes ff go, foe oped such sedative & RELATION. . Por OFNICe ADDRESS ste Rang (Ofve ateoot muinker, if any} | a COPART MEN Ooo in WeHCit Creek > i LS Ae BW nenencenetonctaesecunascueneunsnaneun re, e Be nennewermeensatoceeemonncangnenesscnsogan : . R& ee Cte | paiuttlutlyt At Ate HARE Beaweese enn enenen. ounm awn enaescevensoaare GR “NO™ ANSWER BY PLACING “x” INDICATE “Wes” * IN PROPER tOLUMN* aetna, 3 ARK YOU & CITLIEN OF OR DO YOU Ome ALLATIANCE TO THE UMI7ED SPATES?,. ” stent At Canteen RP econ emer & ARE YOU AN OFICIAL OF EM PLOVER OF ANY STATE, TLANITORY, COUNTY, OR HUNICIPALLTY? cae sn ctrmenenn rnin avenneonecanmatenteessmreeetsorerameen seem ff your anavwer is Yes", give Getails in liom 10, eee teen re Nscaansnte intimin fares 7, DG YOU REVIT ANY ANNUITY Fate INE CNISED A TATES G8 OS PRICY OF Colusa TRNMTNT UNCER ANY RETIN MENT ACT OR ANY PLEUTION OR OTRER COMPENSATION FOR MILITARY OA NAVAL SERVIC? If your anaweris Veo", dies in Preat!0 reason foe retirement, that ja, age. optional disedilier, of by esason Of voluntary or juvsluntars sepsration afeae 3 vance’ eeevice; anicueit of Y. and under what retirement’ act; and rating, <[ os Fefiremenr 6 rotisod £1 Guitary or naval service, ; seer rere et a ett on ees a nae ret name nanan ee er een eRe nse Lene wenwe nee ene mem, Ae ane ene eee wene meee & HAVE EMI EN TR BEEN CISTHARG ED OF FOACTO TO RESIGN, FOR MISCONDUCT r’ O#8 UNGATISF ECTORY M RVICE FROM ANY POSITION E. ff your anvews ia Yes’, give in free: 10 the name and addrase of emplayer, date, and reason in each case, . ceennensecomern nnn ae eee sneer tniwanrataran | & SINCE YOUR I6TN BIRTHDAY, HAVE VOU EVER SFM ARRESTED, INCITED, OF TO COURT AS A CLPENSENT IN A CRIMINAL PIOCE PLING. = SUMMONSA st OGRVICE Pe OR EMPBRINOR ED, OR ALAC ED O% PROBATION, Of MAVE YOU Y wee ces feemacawans 4a twee ween tween een eenemens Oe ee ee a EVER OFEN ORS ED FY DUROSS S RATL OR COLLATERAL FOR THE VIOLATION OF AMY Late, ROCKE STGULATROW, OA ORIRANTE CERCLULING MEO TRAFFIC VIQLA TIONS FOR WrdtM A FIRE OR PORPEUTUAY OF MOOR LESS WAS PO GED ff your answes ig Yos"*, fat all such cases under leam 10, a teach vase: (1) The date: (2) rhe nasur: of the uffenes or tiolatwon: 13) the name and Wwatien of the court; (4) the raley Powad, if any, of other dspuution uf the vase. f appointed, your fingerprints wil! be taken, INSTRUCTIONS TO APPOINTING OFFICER The appointing officer before whom the foregolug certificate ts mate ghall OM Criseseatip.—The apy officer is reeponeihie for obarrving the intin, determine to his owe satiafactvon that this apreinten? eoultd be in conformance isiuns of (1) ihe Ciwil Serve Rules and (é} expropnarion acty with the Cul Service Act, apaiicaNe Civil Service Rules and Regulations and i ects of Congress pertaining to appeentiep | This form acu Le ebecked for vung of office, penalon, aultebility in con- Dection with any round of recent wscharge og arrest, afed pesticularly for ehe following: . (1) Identity of aroointes.—The appeinies’s signature and handwriting are to be compared with the apmticaiion andor other pertinent papers, The phyzical appearance may be chewted egainet the micdical certifice The Bppvinice may als be queatrumd on tis penronal history fia agsecment with his Previous atatemenin, (2) Age.——Uf dotinite age timita have been established for the position, it should be determinnd that appheant ss eat outsile the age range for appuintment, Uno such determostin ig mate, the appautment may not be consummated, U. G. Goudeumins Punting or Pisce Ciucasip pro Form @1 ow tes un aitidavit for both purpows and is mreptsbls proof of ailcdetasip pis: ut ihe absence of conflicting evitience. in doubtfsl cases the appeiatorat abould aot be consuinmated until cleasance bes been secured for the certife mg ofive of the Civil Service Comumississ, (4) Members of Farily.—Section 9 of the Civil Service Act provites that whenever there are already two ar more members of @ family serving uncer prodatwaal cr permanent appointment ia the comsetitive ecevice, na Mee mrmber of tach family ie elyable fur probs the compent: The appointucrts of pereae entities to yricran Preference are moe ject to thie requirement, Tre meme iG dors not apply to temporary sppame ata, Doubtful cases misy be referrad to the epprogevate ofhce of ike Civil Service Commission for derision. AS—-Gh2- a shal oF Lermuanent appeariment em -
wuntesues STATEMENT OF PRIOR FEDERAL CIV’ ‘AN AND MILITARY SERVICE 83, AND 51 ; AWD DETERMINATION OF COMPETITIVE STATUS inde TANT: The information on this form Ye uerd Cl) in determining ceeditable service for leave purposes and retention Dap ua recarding agency fet ination of competitive statue. The employee eres) Office shou! ‘complete Pata Ub through V. : erecdits for redtiction in Sores, me, should complete Part Land the PART IL—THIS COLUMN [S FOR PEASONNED OFFICE USE 2. RETENTION GROUP ‘ PART 1 EMPLOTE LS STATEMENT 2, UTE OF BIUTH WIGREM, LEE HN. . | $DEc 1943 3. LIST THE FOLLOWING SHPODMALIGH CONCERNING ALL BIST SAL AND MMOTRICT © PRIOR TC YOUR PRESENT AVFUIN TENT (Dur mut enclude s: sarterey service} §, NAME (Lees, Avot, middle initial) 19. A. CSC STATUS [J] ws [7] no BD. TYPE OF PRESENT APPOINT MERT CF CALERA LE ice YOU HAVE HAD | Ter oF 13. SERVICE RAME AND LOCATION CF AGENCY — SPOS TET MORRO YEAR NONE 4. LIST PERIODS OF ACTIVE SERVICE iN ANY GRANCH OF THE Beit FURLES SOF THE CMTE oTATES TF YOU HAD NO ACTIVE MILITARY SERVICE WRITE UAOKE. tN pte Riaacell -° oA CISC MARGE (Han, of dishon.?) 5. DURING PERIODS OF EMPLOYMENT SHOWN IM ITEM 3. fio 7092 REEVE A TOTAL OF W580 THAN § MONTHS AGGENCE WITHOUT PAY. INCLUDING PEPIOUS OF MERCHANT MARINE SEYY IE, DURING ANY ONE CaLEKDeR vEAt? ("] ves [_] uo IF ARSWET AS “YES.” LIST FOLLOWIIG INFORMATION, 12, TOTAL SERVICE 13. MONCKHEDITABLE SERVICE (Leave purpuses only): TYPE IF KNOWH (LWGP, Furt, Susp, AWOL, Mer Mary 14, NONCPEDITABLE SEAVICE (REF purposes only): & PERMANENT COMPETITIVE CIVIL SERVICE STATUS? 8. DURING THE FEDERAL SERVICE LISTED IM ITEM 3, O10 YOus a<* (ves BY no (if answer is ““Yos,’ 15. RCEMPLOYMENT RIGHTS [jvs [] x0 16. RETENTION RIGHTS [J ves ([] v0 _ 17. EXPIRATION DATE OF RETES- . TION RIGHTS “in what agency wore you aap ayed at the time atatues wae acquired?) 7. ARE YOU: A. The mire oF 4 pisaaieo vereaan? (“] ves [RT 80, B. THE MOTHER OF A DECEASED OR OIS4ELL0 VETERAN? Cl ves Ba i] C. THd UNREMARRIED WIDOW OF A VETERAN? ves fe ws 8, 10 BE EXECUTED BEFORE A NOTARY PUBLIC OR OTHER FESO I awear (or afarm) that the above statements are wrue to the beat of my knowledge and belief. /0 he. wary F966 . Len Vitiher (Gee | D (BATE) OS tesa Subecribed and sworn to before me on this ——___. Zey of mene 1G et ee . ad (MGONTI6} (city) ESTATE) UETHORIZED TO ADMibislcH CATS, SEAL NOTE: If oath is taken before a Notary Public, 12 ate of expiration of his Commission should be shown. INSTRUCTIONS: File this farm on the permanent? side <i the employee's official personnel lalder immediately before of after Vike penonnel action Involved. (OVER) Vetelue
14-00000 a 4 Feet rant uteney Seperate Pikas& Baap INSTRUCTION SHEET SEeves PaEP aaixG ris FO ga . — — one rt me se eames ema : : er VWaebties STATEMENT CF FEDERAL CIVILIAN ANO MILITARY SERVICE [ee Hy vieren | FEDERAL CIYILI ag SERVICE OSeo:8 ation PeEN AGESCH Satis -ageacy er ty eee ! fi a Total Civilian Services |! Vi. MILITARY SERVICE (IMCLUCE antY PERICOS OF ACTIVE DUTY: DO ROT CLUDE TESMNAL Leave) H ‘ : P , TOTAL SEQVICE . d aes —— fo Samy - B 26/11 7 li r | i : Aw Total Military Service eld |y if I hereby certify that the above Civilian ani Military service tg complete i “and sccurate to ‘the beset of my knowledge. i ; | . + ‘ ‘ . natal * 4 il December 1051 Ly CAD LA ; W FOR PERSOMNEL CFEACE USE ORLY sateen ana otra anne : TOTAL CHEDETABLE Gles tee | fy fT eV WAY BF CURPrauie CR BOpPaOeTatmaace REVEAL Site
3490000 * ng OA wcunel te ; cos ©" Security information - be 4 Fad PERSONNEL QUALIFICATION QUESTIONNAIRE 1. Serial No. (no entry) 2. NAME: (last (first) (rniddle 3. Oftice WIGREV, LEE Hocarr| /co/se wmale (1 female (2) 4. Date of Birth) t Decuanser (#23 Marital Status Aq o.Employment Date: Nr. Dependents @ ARCH IPS f 7. Citizenship: 5. Acquired By: (i Birth (2 Marriape Naturalization x U.S, (4) Other(specify) ' Other Year U.S. citizenship acquired, if not by birth SEC. I, EDUCATION ‘| L. Extent: (circle one) . 1, Less than high school 4, Two years college, or less C8, Masters degree 2. High school graduate 3. Over two years, no degree 9%, Doctors degree 3. ‘Bachelor degree - Post-graduate study {minimum 8 sem, hrs.) Trade; Business or 6, Commercial school 7 graduate é, College or Universit study: | _ ; ; Name and location of Dates att'd [Yrs Cornpl Sem College or University Major| Minor | From | To Day INivht ea | Hrs Besraad Vat, Coa. | ; =f ' Bosra MlAss. _ | Hishoa sew? [revs favs lz Peer eee le S40 STORY | reys tev) nro GH) piavidas, Codd P| fee Ile | — la) in¢7} | FIARVARE GRADGAIS . 3. Trade, ommercial, and Specialize Training: Ra Attendance Dates School Military, Intelligence or Investi Specialized schools’ such as inte Bative training (full time duty as a Student in lligence, communications, ordnance disposal, etc.) Attendance Dates School From To Tot. mo's Study or Specialization MIA RK. NISSIAAS LAME IABE & APea ayy 7 SPVBLIES € / VR wees 7 ad | AAay Speci eea Tag PROBPAM, YAS Uarid. LAE tab i anes, > CMOS FOR PERSONNEL SOAVICTS GALM PA POAS » SG i PASEPOA VS AS * & Osa Praa) CF OT og Togas SPO aero Secucty ivecnatler
SEC. U., WORK EXPERIENCE . ; ; ; ; lL, State the nature of duties performed with this orginization, starting with your present position, Approximate dates (month and year) are sufficient, Use a continuation sheet, if necessa ry, to adequately describe vour duties, Pronuiyae sy Toads 7. Tot.mos.2o0 #F ceeription of Dutiesi= gracesad eons OF . ew. . - YO Ppude- aaa ii letcak. et ai : rade 7 Salary Y2OS - Aa thiGkeSO SG RMICS cel caatetane pian LCM GAOT VAG Mise tens 6 st ies ae Lek get Noe Ac ¥ awa Ll LAE fy C8 eee e - a Office Ft/ Col S18 Position : f PD aaa RIE T OTE a Title: AFG LAG EAS CE Oggi g A i ~ SPAR AFIOW 4 RLY OEE ES oe Ceustre wag Peg AE Duty ° SiC ¥API ees cab Sec ee TEE an Title: “ “Stations ove re wegen rT Description of Duties: ~ © af Os Fre al ee, eee] asd £ WB en OR eg Vs APE DyAutad Oar ¢ wf) Sade g? VY Pay, Abit be LIE PI ahi Aude ES “ed Pr PAA 4g 2P OBL At s AA ; : : os AE dd x 2 ~~ 28 ee! 3 ge oe Pes @ 2s AT.g asc , Duty Station, if overseas: Description of Duties: Cease 8: “4 oF a Nf & —- From To. et Grade Salary Office ——— Position Tithe: ~ Duty Tie e - cae oma 4 Dory Station, if overse,._! — + eects an ctoanepsngeanenseeteerpeeree trEconsen