Part 26, page 38

Transcript

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

14. Space for detailed answers. Indicate form numbers or which answers apply. Item No 2 Discription of work cont. b6 Per BOC

[REDACTED - black circle] [REDACTED - black circle]

14G

26 32

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If more space is required, use full sheets of paper approximately the same size as this page. Write on EACH sheet your name, birth date, and examination (or position) title. Attach all sheets to this Statement at the top of Page 3.

ATTENTION: READ THE FOLLOWING PARAGRAPH CAREFULLY BEFORE SIGNING THIS STATEMENT

A false answer to any question in this Statement may be grounds for not employing you, or for dismissing you after you begin work, and may be punishable by fine or imprisonment (U.S. Code, Title 18, Sec. 1001). All statements are subject to investigation, including a check of your fingerprints, police records, and former employers. All the information you give will be considered in reviewing your Statement and is subject to investigation. A false answer to Items 25 A or B could deprive you of your right to an annuity when you reach retirement age in addition to the penalties described above.

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CERTIFICATION b6 Per BOC I CERTIFY that all of the statements made in this Statement b7C Per BOC are true, complete, and correct to the best of my knowledge and belief, and are made in good faith. DATE SIGNED Dec. 17, 1970

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DO NOT WRITE IN THIS BLOCK--FOR USE OF EXAMINING OFFICE ONLY [ ] Refer for medical action [ ] Medical action Approved by [ ] Disapproved (reason):

[Grid with columns:] Announcement No. | Name | Material [ ] | Submitted [ ] | Returned [ ] | Entered Register | Preference | Age Rating | [guess: Grade] | [guess: Final Rating] | 3 Points (Vet) | 10 Points Comp. Dis. | Other 10 Points | Dual | Being Investigated | THIS SPACE FOR USE OF APPOINTING OFFICER ONLY | [ ] 10 Pt. Comp. Disb. [ ] 10 Pt. Other | Preference has been verified through proof that the separation was under honorable conditions, and other proof as required. | Date

[ ] Appt. [ ] Nonpet. Reasons: Form Reviewed: Form Approved: Option

Initials and Date [ ] 5-Pt.

Signature and Title Agency

CSC Form 4-5 rev 8/67 DB Cooper-7191