Fillable Phs-5141-2-12-09-16 FORM PHS 5141-2

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Phs-5141-2-12-09-16 FORM PHS 5141-2

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service Commissioned Corps
APPOINTMENT AFFIDAVIT
REGULAR CORPS
I,
(Name in full)
, do solemnly swear (or affirm) that
A. OATH OF OFFICE
I will support and defend the Constitution of the United States against all enemies, foreign and domestic; that I will bear
true faith and allegiance to the same; that I take this obligation freely without any mental reservation or purpose of evasion;
that I will well and faithfully discharge the duties of the office on which I am about to enter, so help me God.
B. AFFIDAVIT AS TO SERVICE
I am willing to serve in any area or position or wherever the exigencies of the Service may require.
C. AFFIDAVIT AS TO STRIKING AGAINST THE FEDERAL GOVERNMENT
I am not participating in any strike against the Government of the United States or any agency thereof, and I will not so
participate while an employee of the Government of the United States or any agency thereof.
D. AFFIDAVIT AS TO PURCHASE AND SALE OF OFFICE
I have not, nor has anyone in my behalf, given, transferred, promised or paid any consideration for or in expectation or
hope of receiving assistance in securing this appointment.
(Type name of appointee)
(Signature of appointee)
Subscribed and sworn before me this day of , A.D. ,
at
(City)
(State)
Zip Code
(Signature of Notary Public)
(Title)
Appointment and Appointment Date are Established by Personnel Order.
NOTE -- The oath of office must be administered by a person specified in 5 USC Section 2903 or as delegated by the Secretary to the
Deputy Secretary, Assistant Secretary for Health, Assistant Secretary for Administration and Management, or as re-delegated by the
Assistant Secretary for Health to the Surgeon General, Deputy Surgeon General, Assistant Surgeons General or to active duty
Regular Corps officers of the Commissioned Corps of the U.S. Public Health Service who hold the Permanent Director (O-6) grade.
PHS-5141-2
Rev. 8/16
EF
PSC Publishing Services (301) 443-6740
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Phs-5141-2-12-09-16 FORM PHS 5141-2

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Completed 27 February 2020

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