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‘Cattinmnanente 21 REFERENCES —List chree persong living m the United States or Territores of the Usuted Statea who are NOT RELATED TO YOU AND WHO HAVE DEFINITE KNO GE of your qualifications and fitness for the position for which you are applying Do not repeat names of supervisors ssted under Item 16, EXPERIENCE PRESENT BUSINESS OR HOME ADDRESS es ee Men WiTites Tanger J U.S Senator, 2 Sen. Williem Langer Wash. D.C. INDICATE ANSWER BY PLACING “X" IV PROPER COLUMN [YES|NO| _ INDICATE ANSWER BY PLACING “K" IN PROPER COLUMN [YES [NO | 22, (a) Are you # cttizen of the United Srates of America, of {4} as 2 native of American Samoa do you owe allegtance to the 28 May inquiry be made of your present employer regarding United States of America? your character, qualifications, etc? 29 Do you receive or have you applied for an annuity from the United tes or District of Columbia Government under any retirement act Of any pension o¢ other compensation for multtary or naval serysce? If your answer ss "Yes," give delaids in View 34, 30 Are you an offical or employee of any State, Territory, a county, or municipality? Hf your answer ts "Yes," give details in Wem 34. 31 Have you ever been barred by the U § Civil Service Com- mission from thing examinations of eecepting civil service appointments? > / Uf your answer 1s 'Yes,”’ give dates of and reasons for stc: debarmtent in Item 34,” x 32 A Have yea ever been discharged from employment because {t) Your conduct was not satisfactory (2) Your work was not satisfactory? 23 Ace wou now, or have you ever been, a member of the Com- aunise Parry, U § A, or any Communist organization? 2€ Are you now, or have you evec been, a member of a Fascist Organization? ~ a “Ale You gow of have you ever been a member of any foreign or da Oa, association, Movement, group, of com- bination of yStuch 1 rotalstarian, Fascist, Ommunst, oF subversive, of bas adopted, or shows, a policy of advocat- ing Of approving the wsron of acts of force or violence to deny other persons these’-a1 under the Const:cution of the nated States, or which seeks‘to alter the form of government of ¢ United Stares by unconstittt:onalaneans? uatwer ta question 23, 24, or 25 above ss “Yes,” state nie sbeet jo be attached to and made a part of this Pe names 0; iB suc. organizatians, associations, movements froubs, or combination of persons and dates of mem- bership. Give complete detasis of your actroitses therein and make any explanaiion you desire regarding your membership ar achsusties. (See instruciron sheet) B Have you ever resigned after official notification that: (1) Your conduct was not satisfactory (2) Your work was not satisfactory? 26 Does the United States Government employ ian a ervilian capacity any relative of yours (by blood or marriage) with whom you live or have lsved wichin the past 24 months? If your answer 1s Yes’ give sm Item 34 lor FACH such relative (1) full mame, (2) present address, (3) relationship, (4) department or agency by which employed, and (3) kind of appormntiment C Have you ever been discharged from tha Armed Services under other chan honorable conditions? If your answer to A, B, or C 1s Yes,"” grve details 1 Item 34 as clearly as you can remember, including the name and address of employer, approximate date, and reasons tu eath case, 33 Have you ever been arrested charged, or held by Federal State, or other law-entorcement authoritics for any violation o| any Federal law, State law, county or municipal jaw, regulttion or ordingace? Do aot include aayching. that happened before your 16th birthday Do nor snclude traffic violations for which a fine of $23 or less was mmposed All orber charges must be | x | ancluded even if they were dismissed = If your answer 1s "Yes," give in Item 34 for each case (1) If your answer to A, B, or C ss Yes,” grve detasls 1 Item 34, oe mee ahbroxsmate date, (2) charge, (3) place, (4) adooe taken, 34 SPACE TOR DETAILED ANSWERS TO OTHER QUESTIONS Indicate item numbers to which answers apply PumNe tem | wee receive retirement pay from 2 TAs oe you any physical handicap, chronic disease, or other B Have you ever had a nervous breakdown? © Have you ever had tuberculons? - he U.S.Civil Service for m ange snerer en ae ar ena oe ear ena mnie: ad Vice with the FBI, but not Y naval service, If more space 1s required, use paper the same size a3 this page Write on each sheet your name, date of birth, and examination ttle Attach uptime of this application ATTENTION If 30u are apposnted, alt facts you give will be subject to investigation including a check of your fingerprints Before signing this applicae 100, go back over it to make sure you have answered all quescions Correctly and fully, so that your eligrbility can be decided on the basis of ali the facts Admutted unfavorable information about such matters as arrests or duschatges will be considered together with the favorable rnformation i your cecord in determining Present fimess for Federal employment However, a false statement or dishonest answer to any question may be grounds for cancellation of your application or your ssal appointment gad 1s punishable by law on 1 GERTIEY that the statements made by me sn this application are true, complete, end correct to the f my knowledge and belief, and are m wn g att Tn ve si — Date... J flied. ¥ eevnee came Signature of spplicant _ gO? CEG , . 34—63946-3 WM GOVERNMENT PRINTINS OFFICE 7C ; Cee einen celine temne wert meet on at cee A Na ae ne ee