Document Type: 
Document Number (FOIA) /ESDN (CREST): 
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Document Page Count: 
Document Creation Date: 
June 22, 2015
Document Release Date: 
August 18, 2009
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Case Number: 
Publication Date: 
February 9, 1948
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(b)(6) Standard. Form No. 61a Approves J~a~ar~ 28, 1943 U. 5. Ctvt1 Service Commission c. S. c. Dept. Cdr. No. 409 OATH OF OFFICE, AFFIDAVIT, AND ,DECLARATION OF APPOINTEE CEIVTRI~L $~I rf~ ---------------------------------------------yd1 SH NGTO t, ~' ------------------------ (Department or Establishment) (Bureau or Division) (Place of Employment) A. OATH OF I, ------ ._-FJiEIl_AI1 laL------------------------------------------------------------------------------------- Do solemnly swear (or affirm) that I will support and defend the constitution of the United States against all enemies, foreign and domestic; that I will bear true faith and allegiance to the same; that I take this obligation freely, without any mental reservation or purpose of evasion; and that I will well and faithfully discharge the duties of the office on which I am about to enter. SO HELP ME GOD. 8. Do further swear (or affirm) that I do not advocate; nor am I a member of any political party AFFIDAVIT or organization that advocates the overthrow of the Government of the United States by force or violence; and that during such time as I am an employee of the Federal Government, I will not advocate nor become a member of any political party or organization that advocates the overthrow of the Government of the United States by force or violence. DECLARATION OF APPOINTEE Do further certify that (1) I have not paid or offered or promised to pay any money or other thing of value to any person, firm, or corporation for the use of influence to procure my appoint= ment; (2) I will inform myself of and observe the provisions of the Civil Service law and rules and Executive orders concerning political activity; political assessments, etc.; as quoted on the-attached Information for Appointee; and [strike out either (3) or (4)] (3) the answers given by me in the Declaration of Appointee on the reverse of this sheet are true and correct; (4) the answers contai ed in my Application f Federal Employment, Form No., --------- dated _________________ __________________; 19______, ' ed with the above= named department or establishment, w h I have reviewed, ar true and correct as of this date; ex= cept for the following necessary, use ad oval sheet; if no exceptions write none"; if (4) is execute a reverse of this sh t need not be used): APPROVED FOR RELEASE^DATE: 05-Aug-2009 h --------------------------------- --- ---------------- (Signature of Appointee) Subscribed and sworn before me this ---- 9th----- day of --------------- I ebruar7 A. D., 19 8--- at------------Washington--------------------------------------- D. C. - - nua s.? uK. Ttt,., imp $ee. 2t* --- [SEAL] ,???"?~ _ A w? iAf :h,ne 26. 1943 7 _Appo ntment Clerk ---------------------------------------- (Title) NOTE.-If the oath is taken before a Notary Public the date of expiration of his commission should be shown 16--32864-2 ---ebruary_ 19.1$--------- n-fmmati 2b,LL.$Q ----- -'___ (Date of Entrance on Duty) (Position to which appointed) (Date of firth) DECLARATION OF ,APPOINTEE This form, if required, is to be completed before entrance on duty. Every question must be answered. Any false statemment in this declaration will be grounds for cancelation of application or dismissal after appointment. False personation is a criminal offense and will be prosecuted accordingly. 1. Present Address ------ 1_1_IO 1_1_4-Z/7 --------- ------------ -----~.---- -'?"'___ (Street and Number) - ---- ----------------- ------------------- (S t and 1~ et) ~ (City and State) 3. Does the U. S. Governm n employ in a civilian capacity any relative of yours (either by blood or marriage) with whom you live or have lived within the past 6 months? Yes or No?_ _ If so, for each such relative fill in the blanks below. If additional space is necessary, complete under Item 12. Name Post-office address (1) Position and (2) Temporary or not, (3) Department office in which Relation- Married or Age (Give street number, if any) mploya ed employed ship single 2. ---------------------------------- 3 - ----------------------------- -- 1. ---------------------------------- 2. ---------------------------------- 3- ------- -------- 1. ---------------------------------- 2. ---------------------------------- 3. ---------------------------------- ~w`--..- ad'-'" f 4. Place of birth ---------------- .---------------------------------------------C -------------------------------------- (Town) (State or Country) 6. If foreign born, have you furnished proof of naturalization or citizenship to (1) the U. S. Civil Service Commission?__________ (2) this agency in connection with this appointment?_________ 7. Since you filed application resulting in this appointment, has there been any change in the status of your citizenship, or of the persons through whom you gained your citizenship? _________ 8. (a) Do you hold any position or office under the United States or any State, Territory, County, or Municipality?____ ________ If so, state the place, position, and salary under Item 12. (b) Are you willing to resign such position or office if it becomes necessary to do so in order to hold the Federal position?_________ 9. Do you receive any pension or other benefit for military or naval service or an annuity from the U. S. or D. C. Government under any Retirement Act?----------------------------------- If so, give details under Item 12, stating whether you were retired for age, length of service, or disability; amount of retirement pay and under what retirement act; and rank, if retired from military or naval service. 10. Since you filed application resulting In this appointment, have you been discharged for misconduct or unsatisfactory service, or forced to resign from any position?_________ If so, give under Item 12 where employed, name and address of employer and the reason for discharge in each case. 11. Since you filed application resulting in this appointment, have you been arrested, or summoned into any civil or military court as a defendant, or indicted for or convicted of any offense (felony or misdemeanor)? ----------------------------------- If so, for each case give under Item 12 (1) the date, (2) the name and location of the court, (3) the nature of the offense or violation, and (4) the penalty, If any, imposed, or other disposition.. State) T -- ---------- ITEM NO. -Y --- ---------------------------------------------------------------------------- ------------------------------------------------------------------------- ----------------------------------------------------------------------------- 1/ . ------------- --------- --------------------- ---------- ------------------ --------------------------------------------------------- ---------------------------------------------------------------------------- ---------------------------------------------------------------------------- ---------------------------------------------------------------------------- ---------------------------------------------------------------------------- ---------------------------------------------------------------------------- --------------------7------------------------------------------------------- --------------------------------------------------------------------------- ---------------------------------------------------------------------------- ---------------------------------------------------------------------------- ---------------------------------------------------------------------------- The appointing officer before whom the foregoing certificate is made shall determine to his own satisfaction that this appointment would be in conformance with the Civil Service Act, applicable civil-service rules, the War Service Regu- lations, and acts of Congress pertaining to appointment This form should be checked for holding of office, pension, purchase of office, suitability in connection with any record of recent discharge or arrest, promise to observe provisions regarding political activity, and particularly for the following: (1) Identity of appointee with the applicant whose appointment was author- ized. The appointee s signature and handwriting are to be compared with the application and/or other pertinent papers. The physical appearance may be checked against the medical certificate. The appointee may also be questioned on his personal history for agreement with his previous statements. (2) Age.-If discrepancy exists between of birth and that on applica- tion, and if definite age limits have been established for the position, it should be determined that applicant is not outside the ac'- '7nge for appointment (3) Citizenship.-The responsibility for oh ',revisions of appropriation acts prohibiting or restricting the employment o: as lies with the appointing officer. The Civil Service Commission indicates on applications showing foreign birth that citizenship has been verified. The appointing officer should verify citizenship if the list of eligibles or the letter of authority from the Commission makes the appointment subject to proof of citizenship, or if the application shows foreign birth but does not indicate on its face that citizenship has been pproved. If the answer to question 4 of this form shows foreign birth and the pplication shows birth in the United States, the case should be referred to the Ciavil Service Commission. (4) Members of Family.-Section 9 of the Civil Service Act provides that when- ever there are already two or more members of the family in the classified service, no other member of such family is eligible for appointment in that service. Minors do not establish a different family merely by living at an address different from that of the parents. Doubtful cases involving more than two members of family, Including all pertinent evidence, should be referred to the Civil Service Com- mission or its duly authors representatives for decision. Under War Service Regulations, the member: 'v provision does not apply to temporary appoint- ments for one year or les. 16--52884-i