DECLARATION OF APPOINTEE

1. Present Address: 6300 St. Charles Avenue, New Orleans, La.
2. Name and address of nearest relative: Mrs. W. P. Dunbar, Wife, 6300 St. Charles Ave., New Orleans, La.
3. Name of person to be notified in case of emergency: Mrs. W. P. Dunbar, Wife, 6300 St. Charles Ave., New Orleans, La.
4. Place of birth: New Orleans, La.

Indicate "Yes" or "No" answers by placing an X in proper column:
5. Are you a citizen of the United States? Yes: X No: __
6. If appointed, have you furnished proof of citizenship to or through the appointing officer? Yes: X No: __
7. Have you ever been convicted of any offense against the laws of the United States? Yes: __ No: X
8. Have you held any position or office under the United States? Yes: X No: __
If yes, state the title and nature of service in the space below: U.S. Marine Corps Officer, Marine Corps Reserve.

Instructions to Appointing Officer:
[Additional text and instructions follow.]