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. Misrepresentation is a criminal offense and will be prosecuted accordingly.

PRIVATE ADDRESS (Street and Number)
2305 Minnesota Ave. S.E.
Washington, D.C.

DATE OF BIRTH
Feb. 20, 1928

PLACE OF BIRTH (City and State or Country)
Forest River, N. Dakota

NAME OF FATHER
Mr. Louis A. Thiel

NAME OF MOTHER
Mrs. Pearl A. Thiel

NAME OF HUSBAND OR WIFE
Miss Marilyn Thiel

OFFICIAL ADDRESS (Street and Number)
3143 W. 134th St.
Denver, Colo.

POSITION
Clerk

NATURE OF APPOINTMENT
Temporary

MARITAL STATUS
Single

INDICATE "YES" OR "NO" BY PLACING "X" IN PROPER COLUMN
YES NO
1. ARE YOU A CITIZEN OF OR OWING ALLEGIANCE TO THE UNITED STATES? X
2. HAVE YOU BEEN DISCHARGED FOR EMPLOYMENT IN ANY STATE, TERRITORY, COUNTY, OR CITY FOR REASONS OF DISLOYALTY TO THE UNITED STATES? X
3. DO YOU RECEIVE ANY ANNUITY FROM THE UNITED STATES AS A RESULT OF RETIREMENT FROM CIVILIAN OR MILITARY SERVICE? X
4. ARE YOU NOW UNDER CHARGES FOR ANY OFFENSE AGAINST THE LAW? X
5. HAVE YOU EVER BEEN ARRESTED, INDICTED, OR CONVICTED FOR ANY VIOLATION OF ANY LAW? X
6. HAVE YOU EVER BEEN DISCHARGED FROM THE ARMED FORCES UNDER OTHER THAN HONORABLE CONDITIONS? X

INSTRUCTIONS TO APPOINTING OFFICER
The appointee above before entrance on duty has completed the above declaration and has answered all questions. The appointee has been informed that any false statement in this declaration will be grounds for cancellation of application or dismissal after appointment. Misrepresentation is a criminal offense and will be prosecuted accordingly.