APPOINTMENT AFFIDAVITS - MAKSYMIEC, MYROSLAW ANDREW

• Document Type: FOIA
• Keywords: PERSONNEL FILES
• Keywords: MAKSYMIEC MYROSLAW ANDREW
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 0001517115
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 2
• Document Creation Date: June 22, 2015
• Document Release Date: August 26, 2008
• Case Number: F-2008-00615
• Publication Date: November 27, 1961

STANDARD FORM 61
REVISED JUNE 1957
U. S. CIVIL SERVICE COMMISSION
F. P. M. CHAPTER A6.
APPROVED FOR
RELEASE DATE:
11-Aug-2008
APPOINTMENT .AFFIDAVITS
IMPORTANT: Before -swearing to these appointment affidavits, you should read and..understand
the attached information for appointee
CENTRAL INTELLIGENCE AGENCY WASHINGTON, D. C.
(b)(3)
(b)(6)
1,7-ROSLAUT ATTDREW 1`----- "1ZEC do solemnly swear (or affirm) that-
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OATH OF OFFICE
A.
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 .office 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 knowingly a member of any
organization that advocates the overthrow of the constitutional form of the Government of the
United States, or which seeks by force or violence to deny other persons their rights under the
Constitution ' of the United States. I do further swear (or affirm) that I will not so advocate,,
nor will I knowingly become a member of such organization during the period that I am an em-
ployee of the Federal Government or any agency thereof.
C. 'AFFIDAVIT AS TO STRIKING AGAINST THE FEDERAL GOVERNMENT
I am not participating in any strike against the Government of the United States or any
agency thereof, and I will not so participate while an employee of the Government of the United
States or any agency thereof. I do not and will not assert the right to strike against the Govern-
ment of the United States or any agency thereof while an employee of the Government of the
United States or any agency thereof. I do further swear (or affirm) that I am not knowingly a
member of an organization of Government employees that asserts the right to strike against. the
Government of the United States or any agency thereof and I will not, while an employee of the
Government of the United States or any agency thereof, knowingly become a member of such an
organization.
D. AFFIDAVIT AS TO PURCHASE AND SALE OF OFFICE
I have not, nor has anyone acting in my behalf, given, transferred, promised or paid any con-
sideration for or in expectation or hope of receiving assistance in securing such 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.
(Date of entrance on duty)
27 Nov 61
Subscribed and sworn before me this ------------------ day of --------------------------------------------- A. D. 19------,
at Washington, D.C.
-------------------------------------
(City)
[SEAL]
Personnel C
----------------------------------- ----------------- -----------------
(Title)
NOTE.-The oath of office must be administered by a person specified in 5 U. S. C. 18, or by a person designated to
administer oaths under Section 206, Act of June 26, 1943, 5 U. S. C. 16a. If by a Notary Public, the date of
expiration of his commission should be shown.
 DECLARATION OF APPOINTEE
This form is to be completed before entrance on duty. Answer all questions. Admitted unfavorable
information about such matters as arrests or discharges will be considered together with the:?favorable information
in your record in determining your present fitness for Federal employment. However, a false statement or
dishonest answer to any question may be grounds for dismissal after appointment and is punishable bylaw.
1. PRESENT ADDRESS (street and number, city and State)
2. (A) DA E OF BIRTH (B) PLACE OF BIRTH (city and State or city and foreign country)
, - - '
JO ,4 LW i /5 "? IAf 4,/Cfff.,(-TEo~' /~/Fl~ i ? - 4 /'f'//T E
3. (A) IN CASE OF EMERGENCY, PLEASE NOTIFY (B) RELATIONSHIP (C) STREET AND NUMBER. CITY AND STATE (D) TELEPHONE NO.
Al 0l9.g J' 41,t - WIPE ? 9~~x
~~ Tom' 6'x.2/
d~
4. DOES THE UNITED STATES GOVERNMENT EMPLOY. IN A CIVILIAN CAPACITY. ANY RELATIVE OF YOURS (EITHER BY BLOOD OR MARRIAGE) WITH WHOM YOU LIVE OR HAVE LIVED WITHIN
THE PAST 24 MONTHS? 0 YES ?.Ne
11 30, for each such relative fill in the blank below. If additional space is necessary, complete under Item 12.
POST OFFICE ADDRESS
(Give (Give street number, if any)
(1) POSITION (2) TEMPORARY OR NOT
(3) DEPARTMENT OR AGENCY IN WHICH
RELATIONSHIP
MAR- SIN.
RIED GLE
EMPLOYED
(Check one)
3. 9 OA
3~G T 1r fF'NC
------------------------------------------
3.
INDICATE ANSWER BY PLACING "X" IN PROPER COLUMN
YES
NO
INDICATE ANSWER BY PLACING "X" IN PROPER COLUMN
YES
NO
5.(A) ARE YOU A CITIZEN OF THE UNITED STATES OF AMERICA, OR (B) AS A
NATIVE OF AMERICAN SAMOA DO YOU OWE ALLEGIANCE TO THE UNITED
IS. (A) HAVE YOU EVER FILED A WAIVER OF LIFE INSURANCE COVERAGE
UNDER THE FEDERAL EMPLO
'
STATES OF AMERICA?
YEES
GROUP LIFE INSURANCE ACT?
6. ARE YOU AN OFFICIAL OR EMPLOYEE OF ANY STATE. TERRITORY, COUNTY, OR
MUNICIPALITY?
(B) IF YOU HAVE FILED SUCH A WAIVER, HAS IT BEEN CANCELED OR
REVOKED?
If your answer is "Yes," give details in Item 12.
7. DO YOU RECEIVE OR HAVE YOU APPLIED FOR AN ANNUITY FROM THE UNITED
STATES OR DISTRICT OF COLUMBIA GOVERNMENT UNDER ANY RETIREMENT
11. SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT:
ACT OR ANY PENSION OR OTHER COMPENSATION FOR MILITARY OR NAVAL
A. HAVE YOU BEEN DISCHARGED FROM EMPLOYMENT BECAUSE:
SERVICE?
(1) YOUR CONDUCT WAS NOT SATISFACTORY?
If your answer is "Yes,"
give details in Item 12.
(2) YOUR WORK WAS NOT SATISFACTORY
L SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT, HAVE YOU
BEEN ARRESTED. CHARGED. OR HELD BY FEDERAL, STATE. OR OTHER LAW
ENFORCEMENT
T
O
?
B. HAVE YOU RESIGNED AFTER OFFICIAL NOTIFICATION THAT:
AU
H
RITIES. FOR ANY VIOLATION OF ANY FEDERAL LAW,
STATE LAW, COUNTY OR MUNICIPAL LAW, REGULATION OR ORDINANCE? DO
(I) YOUR CONDUCT WAS NOT SATISFACTORY?
NOT INCLUDE TRAFFIC VIOLATIONS FOR WHICH A FINE OF $25 OR LESS WAS
IMPOSED. ALL OTHER CHARGES MUST BE INCLUDED EVEN IF THEY WERE
(2) YOUR WORK WAS NOT SATISFACTORY?
DISMISSED.
If your answer is "Yes " give in Item 12 for each case:
(1) approximate date, (2 charge, (3) place, (4) action taken.
C. HAVE YOU BEEN DISCHARGED FROM THE ARMED SERVICES UNDER
OTHER THAN HONORABLE CONDITIONS?
9. SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT, HAVE
YOU BEEN BARRED BY THE U.S. CIVIL SERVICE COMMISSION FROM TAKING EXAMINATIONS OR ACCEPTING CIVIL SERVICE APPOINTMENTS
If your answer to A, B, or C is "Yes," give details in
Item l2-as clearly as ou
c n r
cl , in r
?
If your answer i
I "Yes," ive dates of and reasons for
g
d~t~k~ eb ?~a~?..
~ ~ WE. Ka
S1}1~
such debarment in Item I
t"1E 4.i.S~t
12. SPACE FOR DETAILED ANSWERS TO OTHER QUESTIONS (Indicate item numbers to
w1s1.a'
-- 77: -------
INSTRUCTIONS TO APPOINTING OFFICER.-You mus' $ ermine that this, appointment would be in conformance
with the Civil Service Act, applicable Civil Service Rules and Regulations, and acts of Congress pertaining to appointment.
This form should be checked for holding of office, pension, any record of recent discharge or arrest, age, citizenship, and mem-
bers of family. Also, to establish the identity of the appointee, you should particularly check (1) his signature and handwriting
against the application and/or other pertinent papers and (2) his,physical appearance against the medical certificate.
ITEM NO.
ITEM NO.
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