APPOINTMENT AFFIDAVITS - JACK M. BANE (W/ATTACHMENT)

• Document Type: FOIA
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 0001034516
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 2
• Document Creation Date: June 22, 2015
• Document Release Date: September 17, 2009
• Case Number: F-2002-00562
• Publication Date: April 6, 1953

STANDARD FORM 61 (REVISeD AuGUS7 tx3)
PROMULGATED BY CIVIL SERVICE COM1IMISSION
FEDERAL PERSONNEL MANUAL
APPOINTMENT AFFIDAVITS
IMPORTANT. Before swearing to these appointment affidavits, you should read and understand the
attached information for appointee
CEIaTRAL INTELLIGEI~E AGENCY WkSHINGTON~ D . C .
--------------------
- - -------------------------------------------------------
(Department or agency) Bureau or division -----------------------------------
( ) (Place of employment)
Jack M. Bane
I~ ---------------------------='--------------------------------------------------------. do solemnly swear (or affirm) that-
A. OATH OF OFFICE
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; that I will well and faithfully discharge the
duties of the or'1ice on which I am about to enter, SO HELP ME GOD.
B. AFFIDAVIT AS TO SUBVERSIVE ACTIVITY AND AFFILIATION
I am not a Communist or Fascist. I do not advocate nor am I a member of any organization
that advocates the overthrow of the Government of the United States by force or violence or other
unconstitutional means or seeking by force or violence to deny other persons their rights under the
Constitution of the United States. I do further swear (or affirm) I will not so advocate, nor will
I become a member of such organization during the period that I am an employee of the Federal
Government.
C. AFFIDAVIT AS TO STRIKING AGAINST THE FEDERAL GOVERNMENT
I am not engaged in any strike against the Government of the United States and that I ~~ill not
so engage while an employee of the Government of the United States; that I am not a member of
an organization of Government employees that asserts the right to strike against the Government
of the United States, and that I will not, while a Government employee, become a member of such
an organization.
D. AFFIDAVIT AS TO PURCHASE AND SALE OF OFFICE
I have not paid, or offered or promised to pay, any money or other thinguof value to any person,
firm or corporation for the use of influence to procure my appointment.
E. AFFIDAVIT AS TO DECLARATION OF APPOINTEE
The answers given in the Declaration of Appointee on the reverse of this form are true and
correct. ,
6 ~p~ 195 '
_______________________________ y ^ .-_
-~ ~
V:Da[e nr mMan.-w n.. A.....1 ~----_____ _~- _ ______r-_ __ 'frjl ~(~j~2~
Subscribed and sworn before me this ___-_ 6~_-_____ day of _-_ AI?r~_________________________________ A: D. 19__5
at---------------------------------- ~~hingtQiz-----------------
(City)
------------------------ D'- C?-
- ------------------------------
(Stete)
(Title)
NOTE. If the oath is taken before a Notary Public the date of expiration of his commission should
be shown.
t~saiao-a
APPROVED FOR
RELEASE^DATE:
10-Sep-2009
 DECLARATION Of APPOINTEE
This 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 appoiiltment: Impersonation is a
criminal offense and' will be. prosecuted accordingly.
1. PRESENT ADDRESS (atzee! end number, city end State) "' ~- - ~ ..
02 ~ ~ 1 PA-2 K R ~ . N'. Y-/ ? , y V >~5 H 1)~1 GTD )`I) D C .
2 (lV DATE OF BIRTH (B):PLACE OF Blg'[rl (city ex town end State or.eavntry) - s _, e
& (A) INCASE OF EMERGENCY PLEASE NOTFY - I (B) RELATIONSHIP I (C) STREET ND NUMBER, CITY AND SPATE (D) TELEPHONE NO., -,
~IF'i~
-7 I n1t)Rw::s~ f~-v~, ~L3.R1JV N?~. $-3:cs 6
l DOES THE UNITED STATES GOVERNME EMPLOY, IN A CIVILIAN CAPACfTY, ANY RELATIVE OF YOURS (EITHER BY BLOOD OR MARRIAGFa WRH WHOM YOU UVE OR HAVE LIVED WRHIN
THE PAST 21 MONTHS? ~ YES ~O
If so, for each ouch relative fill in the b/enks below. If additional apace is necessary, complete under Item 10.
POST OFFICE ADDRESS ~ O) P061TION ~ (2) TEMPORARY OR NOT ' RELATION- ~ ~ MAR- SINGLE
~~' ?' '~ME ..' `': ;~ (Give street number, if any) (3) DEPARTMENT OR AGENCY IN WHICH SHIP RIED
EMPLOYED (Check one)
1. _____~___-______~__>___ __-_
2 __________________-_>__->- __
9._ ...
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..
.. ~ ... .. ,
2 ----------------------------------
1. ~ ----'----'---------'
.. ..
-
3.
INDICATE "YES" OR "NO" ANSWER BY PLACING "X"
10. SPACE fOR DETAILED ANSWERS TO OTHER QUESTIONS
IN PROPER COLUMN
YES
ND
INEOM
WRITE IN LEFT COLUMN NUMBERS OF ITEMS TO WHICH DETAILED ANSWERS APPLY
S. ARE YOUAC1T72EN OF OR DO YOU OWEALLEGIANCE TO THE UNTED STATES7~
X
~\
_ ,_ -
fi. ARE YOU AN OFFICIAL OR EMPLOYEE OF ANY STATE. TERRITORY. COUNTY. OR
______
____________________________________________________________________-_______>~
MUNICIPALITY?
If
i
"Y
i
d
il
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t
i
Il
10
your answer
s
ea
ve
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e
a
s
n
em
.
7. DO YOU RECEIVE AHY ANNUTfY FROM THE UNITED STATES OR DISTRICT OF
CALUMBIA GOVERNMENT UNDER ANY RETIREMENT ACT OR ANY PENSION OR
______
__________________________________________>_____________________>-______->_
OTHER COMPENSATION FOR MILRARY OR NAVAL SERVICE7~
If your answer ia"Yea", ~rve in Item lO reason for retirement,
th
t i
ti
l d
bilit
b
f
l
y
/
->~--
---~-~---------------------------~------------~>---~-~~-------~--~-----------
s, age, op
ona
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isa
y, or
y reason o
vo
untary
or involuntary aepuetion after S years' service; amount of
~
`
______
______________________________________________________ _____~
~ ~ '
retirement pay, end under what retirement act; end rating,
_>___
_________________________________________>____________-____________-________
it retired from miGtaq or naval eezvice.
B. SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT HAVE YOU
~ ~ ~~ ~ - -
-
BEEN DISCHARGED. OR FORCED TO RESIGN. FOR MISCONDUCT OR UNSIITIS
~
~
----?
-?----___-_---_______-__'_______________________~
'-'-'---'-'--'-'--?-----
FACTORY SERVICE FROM ANY POSITION?
-
-.T-.-~_r-w_?_____~_____
IT
f
"Y
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1
h
.?
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"'-__w~__"
y our answer
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es
, g
ve
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tem
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e name end address
of em
lo
er
dote ~adreaso
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y
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eeo
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tees.
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_
9: HAVE YOU BEEN ARRESTED (NOT INCLUDING TRAFFIC VIOLATIONS FOR
-
,.
----__->~_______________________>~______>_>________________>>>>~
WNICH YOU WERE FlNED>ZS OR LESS, OR FORFEITED COLLATERAL OF 1250R
LESS) SINCE YOU Fn rn APPIJCATION RESULTING IN THIS APPOINTMENT7_
~-_
>_--_____>_______________________>>->_____-_____________>_~___>>.
If your enewer is "Yes", Sat all evch caeca under Item 10.
~
~---
------------------------------------------------------------------->`---------
Give in each case: (I) The de te; (?) the nature of the o8enae
_>-_
_____>__________________________________________________________ _
or violation; (9) the name and location of the court; (t) the
>>-
penalty impwed, if erey, or other disposition of the case.
~>>-
--~----u------------~----~~~~-~-----~--~---~---~>------`-'~~"--'
If appointed, your 6nger,Qrinta will be taken.
The appointing olfieer before whom the foregoing .certificate is made shell
determine to hin own satiafaMioa that this appoiatmrnY would be is conformance
with the Civil Service Act, applicable Civil Service Rules and Regulations cad
acts oC Congrew pertaining to appointment.
This form should be checked for holding of office, pension, avitability in eon-
aection with any record of recent discharge or arrest, and particularly for the
following:
(1) Identity of appoialee.-It is ~ the duty of the appoiaiog officer to
guard against inpexsonation and to determine beyond reasonable doubt that the
appointee ea the same person whose eppoentment was authorized. The
appointee's signature cad headwritiag ere to be compered wish the app8cation
e~/a other pertinent Dopers. It the appointee qualified is a written a=eml-
aation, the signature on this form should be compared with the signature oa
the declaration sheet, which was signed in the ezeminetion room. Flea physical
appearance may be checked against the medical certificate. The eppoiatee
may also be questioned en hie personal history fat agreement with his Drevious
atatemenb,
(T/ Age.-If definite age limits have bees established for the position, it shoald
be determined that applicant is not outside the age range far sppointmrnt.
Until such determination is made the appointmrnt may not be eoaaummeted.
(3) Citiaenship.-The appointing officer is responsible for observing the
citizenship provuiona of (1) the Civil Service Rules cad (2) appropriation acts.
Form 61 coaatituta as affidavit for both purposes cad is acceptable proof of
ehtiunahip atatw in the absence of conflicting evidrnce, In doubtful cases the
appointment ahoold sot be consummated until clearance has been secured from
the certifying office of the Civil Service Commission.
(4) Members of Femily.~SecL'on 9 ed the Civil Service Act provides that
avhenever there are' elrendy taro or more members of a family serving wader
probational er permanent appointment is the competitive service, no other
member of nueh family is eligible far probational or permanent appointment in
the competitive servitt. The appointments of persons entitled to veteran
preferrnee ere not subject to this req??:*e?+?~nt. The members-of-family provision
does not apply to temporary appointments. Doubtful cases rosy be referred to
the appropriate office o[ the -~- tit Service Commisaioa for decisiaa,