ARMY NATIONAL GUARD ENLISTMENT DATASHEET
COMPLETE ALL QUESTIONS IF APPLICABLE. ALL INFORMATION IS NEEDED FOR ENLISTMENT.
SSN:______________________________
FULL NAME(BIRTH CERTIFICATE):
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LAST
FIRST
MIDDLE
II, JR., SR. etc
NAME ON SOCIAL SECURITY CARD:_______________________________________________________
ADDRESS:____________________________________________________________________________
STREET
CITY
STATE ZIP
HOME PH#__________________________ CELL PH#__________________________
WORK NAME:____________________________________ WK #:_______________________________
ADDRESS:______________________________________________________________________
STREET
CITY
STATE ZIP
EMAIL ADDRESS:______________________________________________________________________
DATE OF BIRTH:_______________________
YYYY/MM/DD
PLACE OF BIRTH:______________________________________________________________________
CITY
STATE
COUNTY
HEIGHT:___________ WEIGHT:__________ EYE COLOR:___________ HAIR COLOR:__________
DRIVERS LICENSE #:_________________________________ EXP DATE:___________ STATE:________
MARITAL STATUS:__________________ # OF DEPENDENTS__________ # OF MINORS________
AGE 0-17
EDUCATION LEVEL:_________ HIGH SCHOOL & GRADUATION YEAR:____________________________
COLLEGE(S) ATTENDED:_________________________________________________________________
RACE:________________ ETHNICITY:________________ RELIGIOUS PREFERENCE:________________
MEDICAL PROVIDER INFORMATION:
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PHYSICAL SCREENING (PLACE A CHECK MARK NEXT TO ALL THAT APPLY)
1.
Asthma, wheezing or inhaler use (4)
2.
Dislocated joint, including knee, hip, shoulder, elbow, ankle, or other joint (1)(7)
3.
Epilepsy, fits, seizures, or convulsions (4)
4.
Sleepwalking (4)
5.
Recurrent neck or back pain (4)(1)(7)
6.
Rheumatic Fever (4)
7.
Foot pain (3)
8.
A swollen, painful, or dislocated joint or fluid in a joint (knee, shoulder, wrist, elbow, etc.) (1)(7)
9.
Double vision (4)
10. Periods of unconsciousness (4)
11. Frequent or severe headaches causing loss of time from work or school or taking medication to prevent
frequent or severe headaches (4)
12. Wear contact lenses (If so, bring your contact lens kit and solution so you can remove your contact when
we test your vision at the MEPS; also, if you have a pair of eyeglasses, bring them with you no matter how
old they are.) (4)
13. Fainting spells or passing out (4)
14. Head injury, including skull fracture, resulting in concussion, loss of consciousness, headaches, etc. (4)
15. Back surgery (4)
16. Seen a psychiatrist, psychologist, social worker, counselor or other professional for any reason (inpatient
or outpatient) including counseling or treatment for school, adjustment, family, marriage or any other
problem, to include depression, or treatment for alcohol, drug or substance abuse (6)(2)
17. Skin disease: Eczema (5)
18. Skin disease: Psoriasis (5)
19. Skin disease: Atopic Dermatitis (5)
20. Irregular heartbeat, including abnormally rapid or slow heart rates (4)
21. Allergic to bee, wasp, or other insects stings (itching/swelling all over and/or get short of breath) (4)
22. Heart murmur, valve problem or mitral valve prolapse (4)
23. Allergic to wool (4)
24. Heart surgery (4)
25. Been rejected for military service (temporary or permanent) for medical or other reasons (4)
26. Any other heart problems (4)
27. High blood pressure (4)
28. Discharged from military service for medical reasons (4)
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29. Ulcer (stomach, duodenum, or other part of intestine) (4)
30. Received disability compensation for an injury or other medical condition (4)
31. Hepatitis (liver infection or inflammation) (4)
32. Intestinal obstruction (locked bowels), or any other chronic or recurrent intestinal problem, including
small intestine or colon problems, such as Crohn's disease or Colitis (4)
33. Detached retina or surgery for a detached retina (4)
34. Surgery to remove a portion of the intestine (other than the appendix) (4)
35. Any other eye conditions, injury or surgery (4)
36. Gall bladder trouble or gall stones (4)
37. Jaundice (4)
38. Missing a kidney (4)
39. Allergy to common food (milk, bread, eggs, meat, fish, or other common food) (4)
40. (Males only) Missing a testicle, testicular implant, or undescended testicle (4)
41. Broken bone requiring surgery to repair (with or without pins, plates, screws, or other metal fixation
devices used in repair)
42. Ruptured or bulging disk in your back or surgery for a ruptured or bulging disk (4)
43. Thyroid condition or take medication for your thyroid (4)
44. Limitation of motion of any joint, including knee, shoulder, wrist, elbow, hip, or other joint (4)(1)(7)
45. Drug or alcohol rehab (4)
46. Kidney, urinary tract or bladder problems, surgery, stones, or other urinary tract problems (4)
47. Sugar, protein, or blood in urine (4)
48. Surgery on a bone or joint (knee, shoulder, elbow, wrist, etc.) including Arthroscopy with normal findings
(1)(7)
49. Taking any medications
50. Pain or swelling at the site of an old fracture (4)(1)(7)
51. Perforated ear drum or tubes in ear drum(s) (4)
52. Anemia (4)
53. Ear surgery, to include mastiodectomy or repair of perforated ear drum, hearing loss or need/use a
hearing aid (4)
54. Night blindness (4)
55. Arthritis (4)
56. Absence or disturbance of the sense of smell (4)
57. Absence or removal of spleen, or rupture or tear of the spleen without removal (4)
58. Anorexia or other eating disorder (4)
59. Cracked bone or fracture(s) (4)
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60. Bursitis (4)
61. Braces (If you wear or are planning on obtaining braces for your teeth, have the orthodontist submit a
letter stating that braces will be removed before active duty date; release form and sample format can be
found in the Recruiter's Medical Guide.)
62. Loss of finger, toe, or part thereof (4)
63. Loss of the ability to fully flex (bend) or fully extend a finger, toe, or other joint (4)(1)(7)
64. Shoulder, knee, or elbow problem (out of place) (4)(1)(7)
65. Locking of the knee or other joint (4)(1)(7)
66. Giving way of knee or other joint (4)(1)(7)
67. Cataracts or surgery for cataracts (4)
68. Eye surgery, including radical keratotomy, lens implant or other eye surgery to improve your vision (4)
69. Collapsed lung or other lung condition (4)
70. Bed wetting since age 12 (4)
71. Evaluation, treatment, or hospitalization for alcohol abuse, dependence, or addiction (4)(6)
72. Do you use any tobacco products
73. Evaluation, treatment, or hospitalization for substance use, abuse, addiction or dependence (including
illegal drugs, prescription medications, or other substances)
74. Taken medication, drugs, or any substance to improve attention, behavior, or physical performance
(2)(1)(6)
75. Any illness, surgery, or hospitalization not listed above
76. Do you have a current insurance provider
77. Have you had a previous insurance provider
78. Do you have a primary care physician
79. Have you had a previous primary care physician
80. Painful or 'trick' joints or loss of movement in any joint
81. Do you have tattoos?
82. Do you have any body piercings?
83. Do you have any brandings?
84. Any deformities of, or missing fingers or toes
PLEASE LIST ON THE NEXT TWO SHEETS ANY “YES” ANSWERS NUMBER AND DETAILS SUCH AS DATES, LOCATIONS,
FOLLOW-UPS, DIAGNOSIS, PROGNOSIS, ETC.
EXAMPLE: 82. I HAVE MY EARS AND TOUNGUE PIERCED__________________________________________
75. I WAS HOSPITALIZED BEFORE AND AFTER GIVING BIRTH ON 16 JUNE 2005 AT SOCH
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EXPLAINATION OF YES ANSWERS:
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EXPLANATION OF YES ANSWERS (CONT.)
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PERSONAL SCREENING (PLACE A CHECK MARK NEXT TO ALL THAT APPLY)
1.
Do you have a previous marriage?
How Many:
2.
Have you ever been divorced?
How Many:
3.
Are you legally separated?
How Many:
4.
Do you have a former spouse (such as divorced, annulled, widowed, or other spouses) to report?
How Many:
5.
Did you have a marriage annulled?
How Many:
6.
Have you been widowed?
How Many:
7.
Do you presently reside with a cohabitant?
How Many:
8.
Have you used any other names?
How Many:
9.
Have you fathered/mothered any children?
How Many:
10. Is anyone dependent upon you for financial support?
How Many:
11. Do you have custody of any minor children?
How Many:
12. Have you relinquished custody of any child/children?
How Many:
13. Is there any court order or judgment in effect that directs you to provide alimony and/or child support?
14. Have you served in any branch of Armed Services to include the National Guard?
15. Been rejected for military service (temporary or permanent) for medical or other reasons (4)
16. Do you have an immediate relative (father, mother, brother or sister) who: (1) is now a prisoner of war or
is missing in action (MIA); or (2) died or became 100% permanently disabled while serving in the Armed
Services?
17. Are you the only living child in your immediate family?
18. Have you ever been rejected for enlistment, reenlistment, or induction by any branch of the Armed
Forces of the United States?
PLEASE LIST ON THIS SHEET ANY “YES” ANSWERS NUMBER AND DETAILS:
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MORAL SCREENING (PLACE A CHECK MARK NEXT TO ALL THAT APPLY)
1.
Have any of the following happened? (If 'Yes', you will be asked to provide details for each
offense that pertains to the actions that are identified below.) 1) In the past seven (7) years have
you been issued a summons, citation, or ticket to appear in court in a criminal proceeding against
you? (Do not check if all the citations involved traffic infractions where the fine was less than
$300 and did not include alcohol or drugs) 2) In the past seven (7) years have you been arrested
by any police officer, sheriff, marshal or any other type of law enforcement official? 3) In the past
seven (7) years have you been charged, convicted, or sentenced of a crime in any court? (Include
all qualifying charges, convictions or sentences in any Federal, state, local, military, or non-U.S.
court, even if previously listed on this form). 4) In the past seven (7) years have you been or are
you currently on probation or parole? 5) Are you currently on trial or awaiting a trial on criminal
charges?
2.
Other than those offenses already listed, have you EVER had the following happen to you? 1)
Have you EVER been convicted in any court of the United States of a crime, sentenced to
imprisonment for a term exceeding 1 year for that crime, and incarcerated as a result of that
sentence for not less than 1 year? (Include all qualifying convictions in Federal, state, local, or
military court, even if previously listed on this form.) 2) Have you EVER been charged with any
felony offense? (Include those under the Uniform Code of Military Justice and
nonmilitary/civilian felony offenses.) 3) Have you EVER been convicted of an offense involving
domestic violence or a crime of violence (such as battery or assault) against your child,
dependent, cohabitant, spouse, former spouse, or someone with whom you share a child in
common? 4) Have you EVER been charged with an offense involving firearms or explosives? 5)
Have you EVER been charged with an offense involving alcohol or drugs?
3.
Other than those offenses already listed, have any of the following happened? (If 'Yes', you will
be asked to provide details for each offense that pertains to the actions that are identified
below.) 1) Have you EVER been issued a summons, citation, or ticket to appear in court in a
proceeding against you? (Include all traffic infractions regardless of the fine amount.) 2) Have
you EVER been arrested by any police officer, sheriff, marshal or any other type of law
enforcement official? 3) Have you EVER been charged, convicted, or sentenced of a crime in any
court? (Include all qualifying charges, convictions or sentences in any Federal, state, local,
military, or non-U.S. court, even if previously listed on this form.) 4) Have you EVER been or are
you currently on probation or parole?
4.
Is there currently a domestic violence protective order or restraining order issued against you?
5.
In the last seven (7) years, have you consulted with a health care professional regarding an
emotional or mental health condition or were you hospitalized for such a condition? Answer 'No'
if the counseling was for any of the following reasons and was not court ordered: 1) strictly
marital, family, grief not related to violence by you; or 2) strictly related to adjustments from
service in a military combat environment. Please respond to this question with the following
additional instruction: Victims of sexual assault who have consulted a health care professional
regarding an emotional or mental health condition during this period strictly in relation to the
sexual assault are instructed to answer 'No'.
6.
In the last ten (10) years, have you been a party to any public record civil court action not listed
elsewhere on this form?
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7.
8.
9.
Has your use of alcoholic beverages (such as liquor, beer, wine) resulted in any alcohol-related
treatment or counseling (such as for alcohol abuse or alcoholism)?
In the last seven (7) years has your use of alcohol had a negative impact on your work
performance, your professional or personal relationships, your finances, or resulted in
intervention by law enforcement/public safety personnel?
Have you EVER been ordered, advised, or asked to seek counseling or treatment as a result of
your use of alcohol?
10. Have you EVER voluntarily sought counseling or treatment as a result of your use of alcohol?
11. Have you EVER received counseling or treatment as a result of your use of alcohol in addition to
what you have already listed on this form?
12. In the last seven (7) years, have you illegally used any drugs or controlled substances? Use of a
drug or controlled substance includes injecting, snorting, inhaling, swallowing, experimenting
with or otherwise consuming any drug or controlled substance.
13. In the last seven (7) years, have you been involved in the illegal purchase, manufacture,
cultivation, trafficking, production, transfer, shipping, receiving, handling or sale of any drug or
controlled substance?
14. Have you EVER illegally used or otherwise been involved with a drug or controlled substance
while possessing a security clearance other than previously listed?
15. Have you EVER illegally used or otherwise been involved with a drug or controlled substance
while employed as a law enforcement officer, prosecutor, or courtroom official; or while in a
position directly and immediately affecting the public safety other than previously listed?
16. In the last seven (7) years have you intentionally engaged in the misuse of prescription drugs,
regardless of whether or not the drugs were prescribed for you or someone else?
17. Have you EVER been ordered, advised, or asked to seek counseling or treatment as a result of
your illegal use of drugs or controlled substances?
18. Have you EVER voluntarily sought counseling or treatment as a result of your use of a drug or
controlled substance?
19. Have you ever tried, used, sold, supplied, or possessed any narcotic (to include heroin or
cocaine), depressant (to include quaaludes), stimulant, hallucinogen (to include LSD or PCP), or
cannabis (to include marijuana or hashish), or any mind-altering substance (to include glue or
paint), or anabolic steroid, except as prescribed by a licensed physician?
PLEASE LIST ON THE NEXT SHEET ANY “YES” ANSWERS NUMBER AND SPECIFIC DETAILS. Provide the
name and date of the Charge, Police Department you were arrested or ticketed from, and Court you
attended for the charge and what the findings of the charge were:
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TECHNOLOGY INFORMATION (PLEASE CHECK ALL THAT APPLY)
1.
In the last seven (7) years have you illegally or without proper authorization accessed or attempted to
access any information technology system?
2.
In the last seven (7) years have you illegally or without authorization, modified, destroyed, manipulated,
or denied others access to information residing on an information technology system or attempted any of
the above?
3.
In the last seven (7) years have you introduced, removed, or used hardware, software, or media in
connection with any information technology system without authorization, when specifically prohibited
by rules, procedures, guidelines, or regulations or attempted any of the above?
PLEASE LIST ON THIS SHEET ANY “YES” ANSWERS NUMBER AND SPECIFIC DETAILS:
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GROUP MEMBER/ASSOCIATIONS (PLEASE CHECK ALL THAT APPLY)
1.
Are you now or have you EVER been a member of an organization dedicated to terrorism, either
with an awareness of the organization's dedication to that end, or with the specific intent to
further such activities?
2.
Have you EVER knowingly engaged in any acts of terrorism?
3.
Have you EVER advocated any acts of terrorism or activities designed to overthrow the U.S.
Government by force?
4.
Have you EVER been a member of an organization dedicated to the use of violence or force to
overthrow the United States Government, and which engaged in activities to that end with an
awareness of the organization's dedication to that end or with the specific intent to further such
activities?
5.
Have you EVER been a member of an organization that advocates or practices commission of acts
of force or violence to discourage others from exercising their rights under the U.S. Constitution
or any state of the United States with the specific intent to further such action?
6.
Have you EVER knowingly engaged in activities designed to overthrow the U.S. Government by
force?
7.
Have you EVER associated with anyone involved in activities to further terrorism?
PLEASE LIST ON THIS SHEET ANY “YES” ANSWERS NUMBER AND SPECIFIC DETAILS:
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FOREIGN HISTORY (PLEASE CHECK ALL THAT APPLY)
1.
Do you have, or have you had, close and/or continuing contact with a foreign national within the
last seven (7) years with whom you, or your spouse, or cohabitant are bound by affection,
influence, common interests, and/or obligation? Include associates as well as relatives, not
previously listed in Family & Associates.
2.
Have you, your spouse, cohabitant, or dependent children EVER had any foreign financial
interests (such as stocks, property, investments, bank accounts, ownership of corporate entities,
corporate interests or businesses) in which you or have direct control or direct ownership?
(Exclude financial interests in companies or diversified mutual funds that are publicly traded on a
U.S. exchange.)
3.
Have you, your spouse, cohabitant, or dependent children EVER had any foreign financial
interests that someone controlled on your behalf?
4.
Have you, your spouse, cohabitant, or dependent children EVER owned, or do you anticipate
owning, or plan to purchase real estate in a foreign country?
5.
As a U.S. citizen, have you, your spouse, cohabitant, or dependent children received in the past
seven (7) years, or are eligible to receive in the future, any educational, medical, retirement,
social welfare, or other such benefit from a foreign country?
6.
Have you EVER provided financial support for any foreign national?
7.
Have you in the past seven (7) years provided advice or support to any individual associated with
a foreign business or other foreign organization that you have not previously listed as a former
employer? (Answer 'No' if all your advice or support was authorized pursuant to official U.S.
Government business.)
8.
Have you, your spouse, cohabitant, or any member of your immediate family in the past seven
(7) years been asked to provide advice or serve as a consultant, even informally, by any foreign
government official or agency? (Answer 'No' if all the advice or support was authorized pursuant
to official U.S. Government business.) For this question, "Immediate Family" means your spouse,
parent, step-parents, siblings, half and step-siblings, children, step-children, and cohabitant.
9.
Has any foreign national in the past seven (7) years offered you a job, asked you to work as a
consultant, or consider employment with them?
10. Have you in the past seven (7) years been involved in any other type of business venture with a
foreign national not described above (own, co-own, serve as business consultant, provide
financial support, etc.)?
11. Have you in the past seven (7) years attended or participated in any conferences, trade shows,
seminars, or meetings outside the U.S.? (Do not include those you attended or participated in on
official business for the U.S. government.)
12. Have you or any member of your immediate family in the past seven (7) years had any contact
with a foreign government, its establishment (such as embassy, consulate, agency, military
service, intelligence or security service, etc.) or its representatives, whether inside or outside the
U.S.? (Answer 'No' if the contact was for routine visa applications and border crossings related to
either official U.S. Government travel or foreign travel on a U.S. passport.) "Immediate Family"
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means your spouse, parents, step-parents, siblings, half and step-siblings, children, step-children,
and cohabitant.
13. Have you in the past seven (7) years sponsored any foreign national to come to the U.S. as a
student, for work, or for permanent residence?
14. Have you EVER held political office in a foreign country?
15. Have you EVER voted in the election of a foreign country?
16. Have you EVER been issued a passport (or identity card for travel) by a country other than the
U.S.?
17. Have you traveled outside the U.S. in the last seven (7) years?
Do you possess a U.S. passport (current or expired? Yes or
No
Provide the following information for the most recent U.S. passport you currently possess:
Provide the issue date of the passport: ____________________
Provide the expiration date of the passport: ___________________________________
Provide your passport number: ________________________________________
Provide the name in which passport was first issued _____________________________________
PLEASE LIST ON THIS SHEET ANY “YES” ANSWERS NUMBER AND SPECIFIC DETAILS:
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BACKGROUND/INVESTIGATION (PLEASE CHECK ALL THAT APPLY)
1.
Have you EVER served in the U.S. Military?
2.
Have you EVER served, as a civilian or military member in a foreign country's military,
intelligence, diplomatic, security forces, militia, other defense force, or government agency?
3.
Have you EVER received a discharge that was not honorable?
4.
In the last 7 years, have you been subject to court martial or other disciplinary procedure under
the Uniform Code of Military Justice (UCMJ), such as Article 15, Captain's mast, Article 135 Court
of Inquiry, etc?
5.
Are you now or have you ever been a deserter from any branch of the armed forces of the
United States?
6.
Have you ever been employed by the United States Government?
7.
Are you now drawing, or do you have an application pending, or approval for: retired pay,
disability allowance, severance pay, or pension from any agency of the government of the United
States?
8.
Are you now or have you ever been a conscientious objector? (That is, do you have, or have you
ever had, a firm, fixed, and sincere objection to participation in war in any form or to the bearing
of arms because of religious belief or training?)
9.
Is there anything which would preclude you from performing military duties or participating in
military activities whenever necessary (i.e., do you have any personal restrictions or religious
practices which would restrict your availability?)
10. Have you ever been discharged by any branch of the Armed Forces of the United States for
reasons pertaining to being a conscientious objector?
11. Have you ever been an officer or a member or made a contribution to an organization dedicated
to the violent overthrow of the United States Government and which engages in illegal activities
to that end, knowing that the organization engages in such activities with the specific intent to
further such activities?
12. Have you ever knowingly engaged in any acts or activities designed to overthrow the United
States Government by force?
13. Has the U.S. Government (or a foreign government) EVER investigated your background and/or
granted you a security clearance eligibility/access?
14. Have you EVER had a security clearance eligibility/access authorization denied, suspended, or
revoked? (Note: An administrative downgrade or administrative termination of a security
clearance is not a revocation.)
15. Have you EVER been debarred from government employment?
16. Were you born a male after December 31, 1959?
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FINANCIAL HISTORY (PLEASE CHECK ALL THAT APPLY)
1.
In the last seven (7) years have you filed a petition under any chapter of the bankruptcy code?
2.
Have you EVER experienced financial problems due to gambling?
3.
In the past seven (7) years have you failed to file or pay Federal, state, or other taxes when
required by law or ordinance?
4.
In the past seven (7) years have you been counseled, warned, or disciplined for violating the
terms of agreement for a travel or credit card provided by your employer?
5.
Are you currently utilizing, or seeking assistance from, a credit counseling service or other similar
resource to resolve your financial difficulties?
6.
Other than previously listed, have any of the following happened to you? (You will be asked to
provide details about each financial obligation that pertains to the items identified below).
7.
In the past seven (7) years, you have been delinquent on alimony or child support payments?
8.
In the past seven (7) years, you had a judgment entered against you. (Include financial
obligations for which you were the sole debtor, as well as those for which you were a cosigner or
guarantor.)
9.
In the past seven (7) years, you had a lien placed against your property for failing to pay taxes or
other debts. (Include financial obligations for which you were the sole debtor, as well as those for
which you were a cosigner or guarantor).
10. You are currently delinquent on any Federal debt. (Include financial obligations for which you are
the sole debtor, as well as those for which you are cosigner or guarantor).
11. Other than previously listed, have any of the following happened?
12. In the past seven (7) years, you had any possessions or property voluntarily or involuntarily
repossessed or foreclosed? (Include financial obligations for which you where the sole debtor as
well as those where you were a cosigner or guarantor)
13. In the past seven (7) years, you defaulted on any type of loan? (Include financial obligations for
which you where the sole debtor as well as those where you were a cosigner or guarantor)
14. In the past seven (7) years, you had bills or debts turned over to a collection agency? (Include
financial obligations for which you where the sole debtor as well as those where you were a
cosigner or guarantor)
15. In the past seven (7) years, you had any account or credit card suspended, charged off, or
cancelled for failing to pay as agreed? (Include financial obligations for which you where the sole
debtor as well as those where you were a cosigner or guarantor)
16. In the past seven (7) years, you were evicted for non-payment?
17. In the past seven (7) years, you had your wages, benefits, or assets garnished or attached for any
reason?
18
18. In the past seven (7) years, you have been over 120 days delinquent on any debt not previously
entered? (Include financial obligations for which you where the sole debtor as well as those
where you were a cosigner or guarantor)
19. You are currently over 120 days delinquent on any debt? (Include financial obligations for which
you where the sole debtor as well as those where you were a cosigner or guarantor)
PLEASE LIST ON THIS SHEET ANY “YES” ANSWERS NUMBER AND SPECIFIC DETAILS:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
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PRIOR SERVICE:
Are you now, or have you ever served in the Coast Guard or Merchant Marines? YES NO
If yes discharge type_____________________
List all of your military service below, including service in Reserve, National Guard, and U.S. Merchant
Marine. Start with the most recent period of service and work backward. If you had a break in service,
each separate period should be listed.
1. From_____________To______________ Branch of Service____________SSN#_________________
yy/mm/dd
yy/mm/dd
MOS______
Highest Grade held_____
RE Code(If known)________ Separation Code________ (If known)
Last unit of assignment:___________________________________City____________________St___
2. From_____________To______________ Branch of Service____________SSN#_________________
yy/mm/dd
yy/mm/dd
MOS______
Highest Grade held_____
RE Code(If known)__________Separation Code________ (If known)
Last unit of assignment:___________________________________City____________________St___
3. From_____________To______________ Branch of Service____________SSN#_________________
yy/mm/dd
yy/mm/dd
MOS______
Highest Grade held_____
RE Code(If known)_________Separation Code_________ (If known)
Last unit of assignment:___________________________________City____________________St___
20
RESIDENCE:
Working back 10 years. All periods must be accounted for in your list. Be sure to indicate the actual
physical location of your residence: do not use a post office box as an address. It must be time
consecutive.
1. FROM__________ TO: PRESENT
yy/mm
PHONE #____________________
STREET __________________________________________ CITY_______________________ ST_____
COUNTY__________________ ZIP________________
PERSON WHO KNEW YOU: NAME_____________________________________ PH#_____________
STREET________________________________CITY_________________________ST ___ ZIP________
2. FROM__________ TO:____________
yy/mm
yy/mm
STREET_________________________________________
CITY____________________________ ST______ COUNTY____________________ ZIP_____________
PERSON WHO KNEW YOU: NAME_____________________________________ PH#_____________
STREET________________________________ CITY_______________________ST _____ZIP________
3. FROM__________ TO:____________
yy/mm
yy/mm
STREET_________________________________________
CITY____________________________ ST______ COUNTY____________________ ZIP_____________
PERSON WHO KNEW YOU: NAME_____________________________________ PH#_____________
STREET________________________________ CITY_______________________ST _____ZIP________
4. FROM__________ TO:____________
yy/mm
yy/mm
STREET_________________________________________
CITY____________________________ ST______ COUNTY____________________ ZIP_____________
PERSON WHO KNEW YOU: NAME_____________________________________ PH#_____________
STREET________________________________ CITY_______________________ST _____ZIP________
PLEASE LIST ADDITIONAL ADDRESSES ON A SEPARATE SHEET.
21
EDUCATION HISTORY
1. FROM__________ TO: ________________
yy/mm
NAME OF SCHOOL __________________________________________
CITY_______________________ ST_____ ZIP________________
CIRCLE SCHOOL TYPE:
GRADUATED? YES OR NO
HIGH SCHOOL OR COLLEGE
IF NOT CURRENT GRADE:________________________
GRADUATION DATE: __________________________
yyyy/mm/dd
PERSON WHO KNEW YOU: NAME_____________________________________ PH#_____________
STREET________________________________CITY_________________________ST ___ ZIP________
PLEASE CIRCLE DEGREE HIGH SCHOOL
ASSOCIATES
BACHELORS
MASTERS
GED
2. FROM__________ TO: ________________
yy/mm
NAME OF SCHOOL __________________________________________
CITY_______________________ ST_____ ZIP________________
CIRCLE SCHOOL TYPE:
GRADUATED? YES OR NO
HIGH SCHOOL OR COLLEGE
IF NOT CURRENT GRADE:________________________
GRADUATION DATE: __________________________
yyyy/mm/dd
PERSON WHO KNEW YOU: NAME_____________________________________ PH#_____________
STREET________________________________CITY_________________________ST ___ ZIP________
PLEASE CIRCLE DEGREE HIGH SCHOOL
ASSOCIATES
BACHELORS
MASTERS
GED
PLEASE LIST ADDITIONAL ADDRESSES ON A SEPARATE SHEET.
22
EMPLOYMENT:
Code: Use one of the codes listed below to identify the type of employment:
1-Active Military Duty
6-Self-employment (Include business name and
2-National Guard/Reserve
or name of person who can
3-U.S.P.H.S. Commissioned
7-Unemployment (Include name of person who can verifiy)
4-Other Federal Employment
8-Federal Contractor (List Contractor, not Federal agency)
5-State Government (Non-Federal employment 9-Other
List your employment activities, beginning with the present and working back 7 years.
1. FROM:_________ TO:PRESENT CODE____EMPLOYER_______________________________
yy/mm
YOUR POSTION:___________________ SUPERVISOR:____________________________________
STREET__________________________________CITY__________________ST____ZIP__________
PHONE#________________
2. FROM____________ TO_____________ CODE_____EMPLOYER_________________________
yy/mm
yy/mm
YOUR POSTION:___________________ SUPERVISOR:____________________________________
STREET__________________________________CITY__________________ST____ZIP__________
PHONE #_________________________
3. FROM__________ TO_________ CODE_____EMPLOYER______________________________
yy/mm
yy/mm
YOUR POSTION:___________________ SUPERVISOR:____________________________________
STREET__________________________________CITY__________________ST____ZIP__________
PHONE #_________________________
4. FROM________ TO__________ CODE____EMPLOYER__________________________________
yy/mm
yy/mm
YOUR POSTION:___________________ SUPERVISOR:_____________________________________
STREET___________________________________CITY__________________ST____ZIP__________
PHONE #_________________________
5. FROM________ TO__________ CODE____EMPLOYER__________________________________
yy/mm
yy/mm
YOUR POSTION:___________________ SUPERVISOR:_____________________________________
STREET____________________________________CITY__________________ST____ZIP__________
PHONE #_________________________
PLEASE LIST ADDITIONAL ADDRESSES ON A SEPARATE SHEET.
23
REFERENCES:
List three people who know you well and live in the United States. They should be good friends, peers,
colleagues, college roommates, etc., whose combined association with you covers as well as possible the
last 10 years. Do not list your spouse, former spouses, or other relatives, and do not to list anyone who is
listed elsewhere on this form.
1. DATES KNOWN:
FROM:_________TO:PRESENT:LAST NAME:_________________FIRST:________________MI:____
yy/mm
STREET_____________________________CITY_______________________ST_________ZIP________
PH#___________________
2. DATES KNOWN:
FROM:_________TO:PRESENT:LAST NAME:_________________FIRST:________________MI:____
yy/mm
STREET_____________________________CITY_______________________ST_________ZIP________
PH#___________________
3. DATES KNOWN:
FROM:_________TO:PRESENT:LAST NAME:_________________FIRST:________________MI:____
yy/mm
STREET_____________________________CITY_______________________ST_________ZIP________
PH#___________________
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YOUR RELATIVES AND ASSOCIATES:
Give the full name, correct code, and other requested information for each of your relatives and
associates, living or dead, specified below.
1-Mother(first) 5-Foster parent
2-Father (second)6-Child (adopted also)
3-Stepmother
7-Stepchild
with you
9-Sister
13-Half-sister
17-Other Relatives
10-Stepbrother 14-Father-in-law 18-Associate
11-Stepsister
15-Mother-in-law 19-Adult Currently living
4-Stepfather
12-Half-brother 16-Guardian living with you
Full Name (If deceased,
check box on the left
before entering name)
8-Brother
Code
Date of Birth
Place of Birth
YY/MM/DD
(City & State)
Country
of Birth
Country(ies)
of Citizenship
Current Street Address
and City (country) of Living
Relatives
State
1
2
25
YOUR MOTHER’S OTHER NAMES:
Maiden Name
Last Name____________________________First______________________Middle_______________
From______________ To________________
yy/mm/dd
yy/mm/dd
Circle: CURRENT/FORMER Name or Married
Last Name____________________________First______________________Middle_______________
From______________ To________________
yy/mm/dd
yy/mm/dd
Circle: CURRENT/FORMER Name or Married
Last Name____________________________First______________________Middle_______________
From______________ To________________
yy/mm/dd
yy/mm/dd
YOUR STEP-MOTHER’S OTHER NAMES (IF APPLICABLE):
Maiden Name
Last Name____________________________First______________________Middle_______________
From______________ To________________
yy/mm/dd
yy/mm/dd
Circle: CURRENT/FORMER Name or Married
Last Name____________________________First______________________Middle_______________
From______________ To________________
yy/mm/dd
yy/mm/dd
Circle: CURRENT/FORMER Name or Married
Last Name____________________________First______________________Middle_______________
From______________ To________________
yy/mm/dd
yy/mm/dd
26
YOUR SPOUSE:
CURRENT SPOUSE. Complete the following about your current spouse only.
Last Name___________________________First Name___________________ Middle______________
SSN:_________________________Citizenship______DOB_______________
yy/mm/dd
Place of Birth:__________________________
CITY
ST
Address if different from yours:
Street_____________________________________
City_______________________________St______County_____________________Zip____________
PH#__________________________ Is your spouse now or have ever been in the Military YES NO
Date Married:_________________Place Married:City____________________________St__________
County____________________
YOUR SPOUSE OTHER NAMES:
Circle: Maiden Name or Married
Last Name____________________________First______________________Middle_______________
From______________ To________________
yy/mm/dd
yy/mm/dd
FORMER SPOUSE:
Last Name___________________________First_______________________Middle________________
Date of Birth_________________________Place of Birth______________________________________
Country(ies) of Citizenship________________________Date Married____________________________
Place Married (Include country if outside the U.S.)_______________________ ____________________
Divorced/Widowed (circle one) YY/MM/DD_________________
If divorced, where is the record located? City (Country)_____________________St_______________
Address of Former Spouse: Street_____________________________________City________________
St_______________________County_______________________Zip_____________________________
Telephone Number_________________________________________
27
DOCUMENTS NEEDED FOR ENLISTMENT (COPIES WILL “NOT” BE SUFFICIENT)
DRIVERS LICENSE
SS CARD
BIRTH CERTIFICATE
BIRTH CERTIFICATE OF CHILDREN
MARRIAGE CERTIFICATE
DIVORCE DECREE
CHILD SUPPORT DOCUMENT
HIGH SCHOOL LETTER
HS DIPLOMA
GED CERTIFICATE
JROTC CERTIFICATE
DD FORM 214
NGB FORM 22
LAST PHYSICAL FOR PRIOR SERVICE
BENEFICIARY FOR LIFE INSURANCE (SGLI)
Circle One: SPOUSE MOTHER FATHER CHILDREN (If not listed, then fill out below)
Amount of life insurance (Circle Amount Desired) 50,000 100,000 150,000 200,000
PRIMARY BENEFICIARY
Name_________________________________________________________________________________
SSN__________________________________________________________________________________
Address Street_________________________________________________________________________
City____________________________________State____________________________Zip___________
Relationship to Insured__________________________________________________________________
CONTINGENT BENEFICIARY
Name_________________________________________________________________________________
SSN__________________________________________________________________________________
Address Street_________________________________________________________________________
City____________________________________State____________________________Zip___________
Relationship to Insured__________________________________________________________________
28