HR - APPOINTMENT AFFIDAVITS - LARUE, ROBERT E

• Document Type: FOIA
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 0005515858
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 2
• Document Creation Date: June 24, 2015
• Document Release Date: March 30, 2011
• Case Number: F-2010-00533
• Publication Date: October 29, 1956

(b)(6)
STANDARD FORM 61 (REVISED AUGUST 1949)
PROMULGATED BY CIVIL SERVICE COMMISSION
FEDERAL PERSONNEL MANUAL
APPOINTMENT AFFIDAVITS
IMPORTANT.-Before swearing to these appointment affidavits, you should read and understand the
attached information for appointee
j
y_Ei Ah_ illTE ~= _iiCE AGENCY r~ashin ton D.C.
------------- --------------------------------- ------------------------------ - ---------
(Department or agency) (Bureau or division) (Place of employment)
I, ____ QBIIR.T___ `,a. T.T_ Lac iJ ----------------------------------------------, 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 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 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.
- 29 cQto ier-1956------ - - ~ ,~-~ ``~ /-------------
sture ore o o a tee
(Date of entrance on duty) (signature ppom)
- appointee)
Subscribed ' and sworn before me this _ 22liZ _-_--_--_ day of _~ = ot?? r
.
irTashincton D .G
(City)
------------------------------------------------------------------
(State)
[SEAL]
Appointment Clerk _. ?., ~'
--------------------- --------------
(Title)
NOTE.-If the oath is taken before a Notary Public the date of expiration of his commission should
be shown.
x8-n 160-2
APPROVED FOR
RELEASEL DATE:
03-Mar-2011
 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.
//Oh .Drycf-n '5t
2. (A) DATE OF BIRTH
.I/If E'P s iP,q ! S.
(B) PLACE OF BIRTH (city or town a tate or country)
rn ; h a . N& .b rds Ka
(B) RELA IONSHIP I (C) STREET AND NUMBER, CITY AND STATE
AJ?I-i 1 lam./3
3. (A) IN CASE OF EMERGENCY PLEASE NOTIFY
Marv V. J EVE I Wife 1104 :Dryden St. Silver Sotino Md) Q 8~ :3S
4. DOES THE ITED STATES GOVERNMENT EMPLOY, IN A CIVILIAN CAPACITY, ANY RELATIVE OF YOURS (EIT R BY BLOOD O MARRIAGE) WITH HO OU LIVE OR HAVE LIVED WITHIN
THE PAST 24 MONTHS? YES NO
If so, for each such relative fil in the blanks below. If additional space is necessary, complete under Item 10.
NAME
POST OFFICE ADDRESS
(3) (I) POSITION DEPARTMENT (2) OR AGENCY TEMPORARY IN OR NOT WHICH
RELATION,
MAR- I
RIED
SINGLE
(Give street number, if any)
EMPLOYED
SHIP
(Chec
k one)
.-----------------------------------------
2-------------------- --------------------
3.
1. --------------------------------------
2.----------------------------------------
1-------------------------------------------
2.--------------------- -------------------
3.
INDICATE "YES" OR "NO" ANSWER BY PLACING "X"
10. SPACE FOR DETAILED ANSWERS TO
OTHER QUESTIONS
IN PROPER COLUMN
YES
NO
ITEM
NO.
WRITE IN LEFT COLUMN NUMBERS OF ITEMS TO WHICH DETAILED ANSWERS APPLY
I ARE YOU A CITIZEN OF OR DO YOU OWE ALLEGIANCE TO THE UNITED STATES?__
X
10 R'ECE3VEB_ R_ 1 ' OU_ P CI t f C ly ~_A _ ? _; 4
ARE YOU AN OFFICIAL OR EMPLOYEE OF ANY ST
6
T
ENT
FOR
EA ;^
ACCRUED ANN AI lfA -
f EHER l 0
.
ATE,
ERRITORY, COUNTY. OR
MUNICIPALITY?-----------------------------------------------------------------
-----
_
_
_ ----
-
-
D.
C.
GOVERNMENT SERVICE?
If your answer is "Yes", give details in Item 10.
X
------
-
-
7. DO YOU RECEIVE ANY 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
i
"Y
"
i
yc
your answer
s
es
, g
ve in Item 10 reason for retirement,
that is, age, optional disability, or by reason of voluntary
i
l
i
'
r
untary separat
or
nvo
on after 5 years
service; amount of retirement pay, and under what retirement act; and rating,
d f
if
ti
ilit
l
i
------
- ~~~p [ ~9~~9 (~ ~g gg q~V ~;t(sp p v~;~~~Y y~y~n ,fig --------------
41; Is}-I;~f-3CFSF-GYiD'-t3'P'~LL'fl-T1'37fiti 71T71Tt"'~
re
re
rom m
ary or nava
serv
ce.
i1
8. SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT HAVE YOU
BEEN DISCHARGED, OR FORCED SI RESIGN, FOR MISCONDUCT -- UN-----
FACTORY SERVICE FROM ANY POSITION?_________________________________
If your answer is "Yes", give in Item 10 the name and address
Y --------------------
of employer, date and reason in each case.
------
------
------- ---------------------------- ----------------'----------"-----------------
I. HAVE YOU BEEN ARRESTED (NOT INCLUDING TRAFFIC VIOLATIONS FOR
- -----------"----------"""--""_"""""_"""'""
WHICH YOU WERE FINED $25 OR LESS. OR FORFEITED COLLATERAL OF $25 OR
LESS) SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT?_
X
------
-----------------------------------------------------------------------------
f your answer is "Yes", list all such cases under Item 10.
------
--------------------------------------------------------------------------------
Give in each case: (1) The date; (2) the nature of the offense
or violation; the name and location of the court; (4) the
penalty imposed, if any, or other disposition of the case.
f appointed, your fingerprints will be taken.
______
___________________________________
----------------------------------------------------------------------------------
The appointing officer before whom the foregoing certificate is made shall
determine to his own satisfaction 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, suitability in con-
nection with any record of recent discharge or arrest, and particularly for the
following:
(1) Identity of appointee.-It is the duty of the appointing officer to
guard against inpersonation and to determine beyond reasonable doubt that the
appointee is the same person whose appointment was authorized. The
appointee's signature and handwriting are to be compared with the application
and/or other (pertinent papers. If the appointee qualified in a written exami-
nation, the signature on this form should be compared with the signature on
the declaration sheet, which was signed in the examination room. His 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 definite age limits have been established for the position, it should
be determined that applicant is not outside the age range for appointment.
Until such determination is made, the appointment may not be consummated.
(3) Citizenship.-The appointing officer is responsible for observing the
citizenship provisions of (1) the Civil Service Rules and (2) appropriation acts.
Form 61 constitutes an affidavit for both purposes and is acceptable proof of
citizenship status in the absence of conflicting evidence. In doubtful cases the
appointment should not be consummated until clearance has been secured from
the certifying office of the Civil Service Commission.
(4) Members of Family.-Section 9 of the Civil Service Act provides that
whenever there are already two or more members of a family serving under
probational or permanent appointment in the competitive service, no other
member of such family is eligible for probational or permanent appointment in
the competitive service. The appointments of persons entitled to veteran
preference are not subject to this requirement. The members-of-family provision
does not apply to temporary appointments. Doubtful cases may be referred to
the appropriate office of the Civil Service Commission for decision.