HR - APPOINTMENT AFFIDAVITS - (SANITIZED)

• Document Type: FOIA
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 0005382560
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 2
• Document Creation Date: June 24, 2015
• Document Release Date: January 31, 2011
• Case Number: F-2009-00333
• Publication Date: September 4, 1952

(b)(3)
(b)(6)_ _
STANDARD FORM 61 (REVISED AUGUST 1949)
PROMULGATED BY CIVIL SERVICE COMMISSION
FEDERAL PERSONNEL MANUAL
APPROVED FOR
RELEASE[] DATE:
04-Aug-201 0
APPOINTMENT AFFIDAVITS
IMPORTANT. Before swearing to these appointment affidavits, you should read and understand the
attached information for appointee
I ____________LjY Z e U ____ __ _ do solemnly swear (or affirm) that--
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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 office on which I am about to enter, SO HELP ME GOD.
E. 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 will 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 thing of 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.
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Subscribed and sworn, before me this ________S__tr____ day of ---------------- "~-r "_~rtt___'-'R - A: D. fl9______,
(city)
(Title)
NOTE.-If the oath is taken before a Notary Public the date of expiration of his commission should
be shown. 16-016o-2
 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 appointment. Impersonation is a
criminal offense and will be prosecuted accordingly.
1. PRESENT ADDRESS (~~ssatreet and number, city and State)
2. (A) DATE OF BIRTH (B) PLACE OF TH (city or town and State or country)
3(A) IN CAGE OF EMERGENCY PLEA-SE /NOTIFY (B) RELATIONSHIP (C) STFZ-Er AND NUMBER. CITYANDSTATE (D) TELEPHONE / NO.
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 PAST24 MONTHS? [!]YES NO
If.., for each such relative fill in the blanks below. Tf additional apace fs necessary, complete under Item 10.
NAME
POST OFFICE ADDRESS
(I) POSITION (2) TEMPORARY OR HOT
(3) DEPARTMENT OR AGENCY IN WHICH
RELATION-
MAR. SINGLE
HIED S
(Give street number, if any)
EMPLOYED
SHIP
(Chock one)
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INDICATE "YES" OR "NQ" ANSWER BY PLACING 14W'
10. SPACE FOR DETAILED ANSWERS TO OTHER QUESTIONS
YES
NO
"
IN PROPER COLUMN
,
fNOM
WRITE IN LEFT COLUMN NUMBERS OF ITEMS TO WHICH DETAILED ANSWERS APPLY
5.
ARE YOU A CITIZEN OF OR DO YOU OWE ALLEGIANCE TO THE UNITED STATES?--
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ARE YOU AN OFFICIAL OR EMPLOYEE OF ANY STATE, TERRITORY, COUNTY. OR
6.
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M UrIICIPALITY?.____.------- _._._____ ._____________-_-_
Tf yovr answer is "Yes", give details I. Item 10.
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__________________
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7. DO YOU RECEIVE ANY ANNUITY FROM THE UNITED STATES OR DISTRICT OF
-
--
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--`--------- -- ---- ---`--- -----------
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COLUMBIA GOVERNMENT UNDER ANY RETIREMENT ACT OR ANY PENSION OR
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--
--
-----------
-
-
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OTHER COMPENSATION FOR MILITARY OR NAVAL SERVICE?----------------------
OTHER
i givbinItem 70reasontoof
s a clear is
l
If
untary
at
vo
that is, , agge, e, y pnal
c
ale
or ar reason voluntary
p
______
___________ __________________________-- -----------------------__---- ___---
ra
.
r
involuntary se separation after 5 years' service; amount of
retirement pay, and under what retirement act; and rating,
lit
i
d f
l
i
-------------------------------------------
ary or nava
serv
ce.
re
rom mi
if ret
-
8. SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT HAVE YOU
-
__--______ _____ _____ ----------------------------------------------------
BEEN DISCHARGED. OR FORCED TO RESIGN, FOR MISCONDUCT OR UNSATIS
FACTORY SERVICE FROM ANY POSIT ION__________________________________
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_______________-----__.___-________________-________________-_______.__
Zf our answer is "Yes", give in Item 10 the came and address
employer
date and reason in each case.
_-__
_______ ___________ __-___-_________-_________________-________-____________
_
,
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9, HAVE YOU BEEN ARRESTED (NOT INCLUDING TRAFFIC VIOLATIONS FOR
WHICH YOU WERE FIMED 125 OR LESS, OR FORFEITED COLLATERAL OF 525 OR
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CESB) SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT? __
If yovr answer I. "Yes", list all such cases under Item 10,
- -
Give in each cases (1) The data; (2) the nature of the effects
or violation; (3) the name and location of the court; (4) the
_- __
___ ____________ _________________________________-__-__________________________
penalty imposed, if any, or other disposition of the ..as.
_______
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11 appointed, your fingerprints will be taken.
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INSTRUCTIONS TO APPOINTING OFFICER
The appointing officer before whom the foregoing certificate is made shall (2) Age.-if definite age limits have been established for the position, it should
determine to his own satisfaction that this appointment would be in conformance be determined that applicant is not outside the age range .or appointment.
With the civil Service Act, applicable Civil Service Rules and Regulations and Until such determination is made, the appointment may not be consummated.
acts of Congress pertaining to appointment, (S) Citizenship. The appointing officer is responsible for observing the
This form should be checked for holding of office, pension, suitability in Co.- citizenship provisions of (1) the Civil Service Rules and (2) appropriation acts.
section with any record of recent discharge or arrest, and particularly for the Norm 61 constitutes an affidavit for both purposes and is acceptable proof of
following: citizenship status in the absence of conflicting evidence. In doubtful cases the
(1) Identity of appointee It is the duty of the appointing officer to appointment should not be consummated until clearance has been secured from
guard against inpersonetion and to determine beyond reasonable doubt that the the certifying office of the Civil Service Commission.
appointee is the same person whose appointment was authw_and . The (4) Members of Family.-Section 9 of the Civil Service Act provides that
appointee's signature and handwriting are to be compared with the application whenever there are already two or more members of a family serving under
audios other Ipcs'tinent papers, IE the appointee qualified in a written esemi- probational or permanent appointment in the competitive service, no other
nation, the signature on tMa form should be compared with the signature on member of such family is eligible for probational or permanent appointment in
the declaration sheet, which was signed in the esammation room. 1-I is physical the competitive service. The appointments of persona entitled to veteran
appearance may be checked against the medical certificate. The appointee preference are not subject to this requirement. The members-of-family provision
may also be questioned on his personal history for agreement with his previous does not apply to temporary appointments. Doubtful cases may be referred to
Statements. the appropriate olilce of the Civil Service Commission for decision.
U. a. sissm.MENT PPINrise OFFICE 111-551609