HR - OATH OF OFFICE, AFFIDAVIT, AND DECLARATION OF APPOINTEE - KLIPA, EDMUND X.

• Document Type: FOIA
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 0005461835
• Release Decision: RIFPUB
• Original Classification: U
• Document Page Count: 2
• Document Creation Date: June 24, 2015
• Document Release Date: August 26, 2010
• Case Number: F-2009-01528
• Publication Date: August 27, 1948

Standard Form No. Gin
Approved January 28, 1943
U. S. Civil Service Commission
C. S. C. Dept. Cir. No. 409
OATH OF OFFICE, AFFIDAVIT,
AND
DECLARATION OF APPOINTEE
MUTHA -I= G OZ-- GET OX---------------------------------------------------- BOST9 f- -?---------------------
(Department or Establishment) (Bureau or Division) (Place of Employment)
EDMUND X. KLIPA .
A.
OATH OF Do solemnly swear (or affirm) that I will support and defend the constitution of the United
OFFICE 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.
B. 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.
C. Do further certify that (1) I have not paid or offered or promised to pay any money or other
DECLARATION thing of value 'to any person, firm, or corporation for the use of influence to procure my appoint-
OF APPOINTEE 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 a veers contained in my A lication for Federal Emplo ent, Form No. _________,
date _ _________________________________ _ 19__--_-, filed with the abo named department
or establl ent, which I have re ' wed, are true and correct s of this date, ex-
cept for the llowing (if necessary, se additional sheet; if no xceptions write
"none"; if (4) ' executed, the reverse o 's sheet need not be use :
(Signature of Appointee)
Subscribed and sworn before me this day of ----------- u- ` St________________________________(A.. D., 19
at -------- o-ton,---2s---------------------------------------- -------------------P assach-asetts
----------------
(City) (state)
[SEAL]
.. _e ~ ' l17n~~.cv%v / q, /q5~ .
NOTE: If the oath is taken before a Notary Public the date of expiration his commission should be shown
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APPROVED FOR
RELEASE^ DATE:
07-Jul-2010
 DECLARATION OF APPOINTEE
This form, if required, is to be completed before entrance on duty. Every question must be answered. Any false statement 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 ----------- 13 Loris Road Danvers, Mass.
---------'------------------------------------------------------ --------------
(Street and Number) (City and State)
2. Who should be notified in case of emergency? -------4r---Helen . Ds_ K11122, Wife
(Name) (Relationship)
13 Loris Road Danvers, Mass,
---------------------------------------------------------------------------------------------------------------------------------------------
(Street and Number) (City and State)
3. Does the U. S. Government,Tgmploy 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?____ ).O_ If so, for each such relative fill in the blanks below. If additional space is necessary, completeunder Item 12.
Name
Post-o address
(1) Position and (2) Temporary or not,
and (3) Department or office in which
Relation-
Married or
Age
(Give street nu umber, if any)
employed
ship
single
. ----------------------------------
2- ----------------------------------
3- ----------------------------------
I? ----------------------------------
2. ----------------------------------
3. ------------------------ ---------
. ----------------------------------
2- ------------ ----------------------
3. ----------------------------------
4. Place of birth ------------------ Salem -------------------------------------------- Massachusetts
(Town) (State or Country)
5. Are you a citizen of the United States? --------------------
6. If foreign born, have you furnished proof of naturalization or
citizenship to (1) the U. S. Civil Service Commission?__________
(2) thisagency 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 at 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.
ITEM
NO.
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INSTRUCTIONS TO APPOINTING OFFICER
The appointing officer before whom the foregoing certificate is made shall officer. The Civil Service Commission indicates on applications showing foreign
determine to his own satisfaction that this appointment would be in conformance birth that citizenship has been verified. The appointing officer should verify
with the Civil Service Act, applicable civil-service rules, the War Service Regu- citizenship if the list of eligibles or the letter of authority from the Commission
lations, and acts of Congress pertaining to appointment. makes the appointment subject to proof of citizenship, or if the application shows
This form should be checked for holding of office, pension, purchase of office, foreign birth but does not indicate on its face that citizenship has been proved.
suitability in connection with any record of recent discharge or arrest, promise to if the answer to question 4 of this form shows foreign birth and the application
observe provisions regarding political activity, and particularly for the following: shows birth in the United States, the case should be referred to the Civil Service
(1) Identity of appointee with the applicant whose appointment was author. Commission.
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 the date 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 age range for appointment.
(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 authorized representatives for decision. Under War Service
Regulations, the members of family provision does not apply to temporary appoint-
ments for one year or. less.
U. S. GOV'