Part 26, page 24

Transcript

The scan is the source; the transcript is machine-generated from it.

ATTACH SUPPLEMENTAL SHEETS OR FORMS HERE Answer all questions correctly and fully

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19. If you have ever been employed by the federal government as a civilian, give your last: Grade Job Title 20. Birth place City: State for Foreign Country: 21. Legal or voting residence (State)

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2. REFERENCES. List three persons who are NOT related to you and who have definite knowledge of your qualifications and fitness for the position for which you are applying. Do not repeat names of supervisors listed under Item 18. EXPERIENCE.

Full Name | Present Business or Home Address (Number, street, city, State and ZIP Code) | Business or Occupation [redacted] | [redacted] | Lt. Col | | USMC(Ret) [redacted] | [redacted] | Lt. USMC [redacted] | Same as above | MSGT USMC

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3. MILITARY EXPERIENCE. A. Have you ever served on active duty in the United States military service? (Exclude tours of active duty for training as a reservist or Guardsman.) If "Yes," complete Items B through F below.

Dates (From-To) | Branch | Serial or Service Number [redacted] | USMC | [redacted]

C. Have you ever been discharged from the armed services under other than honorable conditions? (You may omit any such discharge changed to honorable by a Discharge Review Board or similar authority.)... If "Yes," give details in Item 32

D. Do you claim 5-point preference based on active duty in the armed forces?...

If "Yes," you will be required to furnish records to support your claim at the time you are appointed

E. Do you claim 10-point preference?... If "Yes," complete and attach Standard Form 15, "Claim for 10 point Veteran Preference," together with the proof called for in that form.

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ANSWER ITEMS 24 THROUGH 33 BY PLACING AN "X" IN THE PROPER COLUMN

4. Are you a citizen of the United States?... Yes [X] If "No," give country of which you are a citizen:

5. Before answering this question read Item 25 in the attached instructions. A. Are you now, or within the last ten years have you been, a member of: (1) The Communist Party, U.S.A., or any subdivision of the Communist Party, U.S.A.? (2) An organization that to your present knowledge advocates the overthrow of the constitutional form of government of the United States by force or violence or other unlawful means? B. If your answer to Item A(1) or A(2) is "Yes," write your answers to the following questions in Item 34 or on a separate piece of paper. (1) The name of the organization? (2) The dates of your membership? (3) Your understanding of the aims and pur- poses of the organization or the name of your membership?

6. To insure that you are not placed in a position which might impair your health, or which might be a hazard to you or to others, we need information about the following: Do you have, or have you had, heart disease, a nervous breakdown, epilepsy, tuberculosis, or diabetes?... If your answer is "Yes," answering any one of these, give details in Item 34.

7. Within the last five years have you been fired from any job for any reason?... 8. Within the last five years have you quit a job after being notified that you would be fired?... If your answer to 7 or 8 is also a "Yes," give details in Item 34. Show the name and address (including ZIP Code) of employer, approximate date, and reasons in each case. Your references should agree with your answers in Item 18. EXPERIENCE.

9. Have you ever been convicted or in offense against the law or forfeited collateral, or are you now under charges for any offense against the law? (You may omit: (1) traffic violations for which you paid a fine of $30.00 or less; and (2) any offense com- mitted before your 21st birthday which was finally adjudicated in a juvenile court or under a Youth Offender law.)...

10. While in the military service were you ever convicted by general court-martial?... If your answer to 9 or 10 is "Yes," give details in Item 34. Show for each offense: (1) date; (2) charge; (3) place; (4) court; and (2) action taken.

A. Does the United States Government employ in a civilian capacity or as a member of the Armed Forces any relative of yours (by blood or marriage)? (See Item 31 in the attached instructions sheet.) B. Do you live with, or within the past 12 months have you lived with, any of these relatives who are employed in a civilian capacity? If your answer to A is "Yes," give in Item 34 for each relative: (1) full name; (2) present address (including ZIP Code); (3) relationship; (4) department, agency, or branch of the Armed Forces. If your answer to B is "Yes," also give the kind of apartment held by the relative(s) you live with or have lived with within the past 12 months.

Do you receive or have you applied for retirement pay, pension, or other compensation based upon military or federal civilian service? If your answer is "Yes," give details in Item 34.

Are you an official or employee of any State, territory, county, or municipality? If "Yes," give type of position or cause of [illegible], and indicate, in Item 33, [illegible] whether elected or appointed.

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DB Cooper-6645

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b6 Per BOC b7C Per BOC