Yes

Frequently
No

E Will you accept employment: In Washington, D.C.? F. Will you accept appointment only in certain locations?
No Outside U.S.? Yes No If "Yes," list locations:

Yes

C Do you claim 3-point preference based on wartime military service?
Yes

No

E. Do you claim 10-point preference?
Preference Claim" TYPE:

D. Do you claim 5-point preference hased on service during peacetime
campaign?
Yes (Complete and attach Standard Form 15)

No

Yes No If "Yes," check type of preference claimed and complete and attach Standard Form 15. "Veteran
Compensable disability DisabilityWife
Widow Mother

THIS SPACE FOR USE OF APPOINTING OFFICER ONLY

The information given in answer to Question 18 has been verified with the discharge certificate and/or other proof which shows
that the separation was under honorable conditions.

G. Special qualifications not covered in application. (For example, your most important publications (do not submit copies unless requested); your patents or inventions; public speaking and publications experience; membership in professional or scientific societies, etc.; and honors and fellowships received.)

H. Other schools or training (for example, trade, vocational, Armed Forces, or business). Give for each the name and location of school, dates attended, subjects studied, certificates, and any other pertinent data.

List three persons living in the United States or territories of the United States who are NOT RELATED TO YOU AND WHO HAVE DEFINITE KNOWLEDGE of your qualifications and fitness for the position for which you are applying. Do not repeat names of supervisors listed under Item 19.

FULL NAME

PRESENT BUSINESS OR HOME ADDRESS
(Number, Street, City, State and Zip Code)

BUSINESS OR OCCUPATION

14-70419-3

ANSWER ALL QUESTIONS BY PLACING "X" IN PROPER COLUMN

25. Are you a citizen of the United States of America?. If "No." give country of which you are a citizen:

26. Are you now, or have you ever been, a member of the Communist Party, U.S.A., the Communist Politica! Association, the Young Communist League, or any Communist organization?.

27. Are you now or have you ever been a member of any foreign or domestic organization, association, movement, group, or combination of persons which is totalitarian, Fascist, Communist, or subversive, or which has adopted, or shows, a policy of advocating or approv ing the commission of acts of force or violence to den, other persons their rights under the Constitution of the United States, or which seeks to alter the form of government of the United States by unconstitutional means?.

If your answer to 26 and/or 27 above is "Yes," state on a separate sheet attached to and made a part of this application the names of all such organizations, associations, movements, groups or combination of persons and dates of membership. Gite complete details of your activities therein and make any explanation you desire regarding your membership or activities. (See Instruction Sheet.)

28. Have you any physical handicap, chronic disease, or other disability?.

29. Have you ever had a nervous breakdown'

30. Have you ever had tuberculosis?...

if your answer to 28. 29, or 30 about "Yes." give details in Item 39.

31. Have you ever been barred by the U.S. Civil Service Commission from taking examinations or accepting civil service appointment? (1) your answer is "Yes." give dates of and reasons for such debarment in Item 39.9

32. Does the United States Government employ in a civilian capacity any relative of yours (by blood or marriage) with whom you live or have lived within the past 24 months?.

If your answer is "Yes," give in Item 39 for EACH such relative (1) full name; (2) prèsent address: (3) relationship; (4) department or agency by which employed; and (5) kind of appointment.

33. Do you receive or have you applied for an annuity from the United States or District of Columbia Government under any retirement act or any pension or other compensation for military or naval service?..

If your answer is "Yes" give details in Item 39.

34. Are you an official or employee of any State, territory, county, or municipality?

If your answer is "Yes," give details in Item 39.

35. Have you ever been discharged (fired) from employment for any reason?

36. Have you ever resigned (quit) after being informed that your employer intended to discharge (fire) you for any reason?.

If your answer to 35 or 36 above is "Yes," give details in Item 39. Show the name and address of employer, approximate date, and reason, in each case. This information should agree with statements made in Item 19-Experience.

97. Have you ever been arrested, taken into custody, held for investigation or questioning, or charged by any law enforcement authority? (You may omit: (1) Traffic violations for which you paid a fine of $30.00 or less; and (2) anything that happened before your 16th birthday. All other incidents must be included, even though they were dismissed or you merely forfeited collateral.).

38. While in the military service were you ever arrested for an offense which resuited in a trial by deck court or by summary, special, or general court-martial?..

If your answer to 37 or 38 is "Yes," give details in Item 39. showing for each incident: (1) date, (2) charge, (3) place, (4) law enforcing
authority er type of court or court-martial, and (5) action taken.
Indicate item numbers to which answers apply.
Item No.

39. SPACE FOR DETAILED ANSWERS TO OTHER QUESTIONS. Item No.

If more space is required, use full sheets of paper approximately the same size as this page. Write on each sheet your name, date of birth, and examination title. Attach on inside of this application.

ATTENTION: READ THE FOLLOWING PARAGRAPH CAREFULLY BEFORE
SIGNING THIS APPLICATION

A false or dishonest answer to any question in this application may be grounds for rating you ineligible for Federal employment, or for dismissing you after appointment, and may be punishable by fine or imprisonment (U.S. Code, Title 18, Sec. 1001). All statements made in the application are subject to investigation, including a check of fingerprints, police records, and former employers. All information will be considered in determining your present fitness for Federal employment.

CERTIFICATION

your

I CERTIFY that all of the statements made in this application are true, complete, and correct to the best of my knowledge and belief and are made in good faith.

Signature of applicant

(Sign in ink)

Date

OP3 10-76418-2

10 ICHECK ONE), 11 IF MARRIED, WIDOWED, OR DIVORCED, GIVE FULL NAME AND DATE AND PLACE OF BIRTH OF SPOUSE OR FORMER SPOUSE INCLUDE WIFE'S MAIDEN SINGLE NAME, GIVE DATE AND PLACE OF MARRIAGE OR DIVORCE. (GIVE SAME INFORMATION ARDING ALL PREVIOUS MARRIAGES AND DIVORCES.)

MARRIED

WIDOWER)

DIVORCED

12 DENTIFYING NUMBERS (OTHER THAN SOCIAL SECURITY OR ARMED SERVICES SERIAL, SUCH AS PASSPORT NO, ALIEN REGISTRATION NO. SEAMAN'S CERTIFICATE OF CENTIFICATION, ETC. GIVE ALL, SPECIFYING WHICH.)

ORGANIZATIONS WITH WHICH AFFILIATED (PAST AND PRESENT) OTHER THAN RELIGIOUS OR POLITICAL ORGANIZATIONS OR THOSE WHICH SHOW RELIGIOUS OR POLITICAL AFFILIATIONS (IF NONE, SO STATE)

DATES NAMES AND ADDRESSES OF EMPLOYERS (BEGIN WITH PRESENT AND GO BACK TO JANUARY 1, 1937 CONTINUE UNDER ITEM 21 ON OTHER SIDE IF NECESSARY,
MT) To (M/T)
No., Street, City, State
ZIP Code

Employer

I CERTY THAT THE ABOVE STATEMENTS ARE TRUE, COMPLETE, AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF, AND

CERTIFICATION ARE MADE IN GOOD FAITH.