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fin = "* ~ - SATS 4: Some for Seated saswers, fadaste fan nazttars ty Bhak aniwers apy, a ate er eemarteaseaet “ Announcement No. ' ' win . ‘sy qo _—_—e Discription of work cont b6 Per BOC If more space ts requared, use Soll sheets of paper approximately the saroe sizeas this page. Wrice on EACH sheet your same, bith date, and ¢xamiaiiwa (or position) cee, Actach al sheess to this Scucement at the tor of Pare 3. ATTENTION: READ THE FOLLOWING PARAGRAPH CAREFULLY BEFORE SIGNING THIS STATEMENT A false answer to any question In this Stotemen?t may be grounds for not employing you, or for dismissing you ofter you began work, and may be punishable by fine or Imprisonment (U.S. Codo, Title 18, Sec. 1001}. All statements ara subject to Investigation, jacludiag o check of your fingerprints, police records, and former employers. All the information you give wil be considered in reviewing your Statement cnd Is subject to Investigation. A false answer to Items 25 A o7 B could deprive you of your right to on ennuity when you recth retirement age in addition to the penaitles described above. : CERTIFICATIO b6 Per BOC U CERTIFY chat all of the stacements made in chis Scatement b7C Per BOC are tree, complete, and correce ta the Rest of ny knowledge : ated dale hand ace maade wa good (ith. mv {DATE Dee / YO a DO NOY WRITE IN THIS BLOCK FOR USE OF EXAMINING OCFICE ONLY Pretercene Saatemese No, Eetered Register: barned Retene Maternal aj Sudmncced Lf Recurned Gtale C7] 10 Pe Comp. Dissh. [7] 10-Pe. Orher THIS SPACE FOR USE OF APPOINTING OFFICER ONLY nce has been verified through proof that the sepatation was wodee honoradle conditeons, and other proof as required. > CECCTEe | | Nonappor, Noaatons: Pi Sigdature aad Tarte Vor Reviewed: C7 Argos. n