ACTIVE/RESERVE DENTAL CORPS OFFICER APPLICATION CHECKLIST
Direct Accession 2200 Dental Recall 22001 Dental FAP 22053 Dental HSCP 22007
Dental Student 1925 Dental HPSP 1985 Reserve 2205
ATTENTION All NAVCRUITDISTs: Documents should be attached into O’Tools per the Web O’Tools Standard Operating Procedures.
NAME: SSN: DESIGNATOR:
NAVCRUITDIST PROC: NAVCRUITDIST:
# YES N/A
SCROLL & AFIP SUBMISSION
001 Scroll Pre-Screening Form (NC 1131/67) submitted to CNRC via OPO
002 Submitted to AFIP 2200 and 2205 AFIP Checklist available in Info Center in O’Tools.
003 Application Checklist (NC 1131/62)
004 Application Processing and Summary Record (NC 1131/1)
005 Application for Commission (NC 1131/2) Not required for RECALL applicants
Designator matches Application Processing Summary Record Yes
Dependent Travel Statement of Understanding Initialed Yes
Meets requirements for Third class swim test Yes No, if NO, provide OPO statement to applicant
006 Security Clearance: Does applicant have a current NACLC or higher in JPAS Yes No; if yes must submit
printout of JPAS with kit (cannot be greater than 10 yrs). If no must submit the EPSQ (SF 86) signed and dated by
applicant within past 6 months (Refer to COMNAVCRUITCOM NOTE 5510). Submit to OPM at time of Physical.
007 Birth Certificate or Request Verification of Birth (DD Form 372) if original birth certificate unavailable
008 Evidence of Citizenship Form (NC 1100/25) if naturalized
RECALL (Note: Not eligible if FOS x2)
009 Application for Recall to Ext Active Duty (NP 1331/5) prior commission any service
010 Security Summary (NC 1131/2 sec IV)
011 Military Service Summary (NC 1131/2 sec V)
012 Motivational Statement (NC 1131/2 sec VIII)
ACADEMIC INFORMATION (Note: Not required for Recall)
013 Copies of Official Transcripts include all front and reverse sides for each college attended (Important see Note 1)
014 Academic Degree Completion Plan (NC 1131/4) (HSCP only) Ensure total hours blocks and required hours blocks
completed, applicant is enrolled full time Spring and Fall and signed by Dean/advisor.
015 Academic Year Statement 1985. Not required for kit submission but required before FINSEL. NRD must submit to NMPT&E
with signed Commissioning Documents (Oath of Office & Service Agreement) http://www.nomi.med.navy.mil/pages/nmetc/index.htm
016 GPA Calculation Worksheet (NC 1131/53) include all schools attended
017 Professional School Entrance Exam Report (DAT) 2200, 2205, 22053, 22007, 1985 and 1925
018 Letter of Acceptance to school/residency all students & FAP not yet attending school/residency Applicant for
dental school that has not started school yet will not receive a LOA before December of each year. The PM should be
forwarded these kits with the LOA pending. Applicants applying for 2 yr or 3yr programs should be able to provide
019 Letter of Good Standing with school /residency 22053, 22007, 1985, 1925 and 2200/2205 applying as student.
Letter must include graduation date. (LOGS will be acceptable in place of a LOA for someone already in dental
020 Resume / Curriculum Vitae signed and dated
021 Professional Community Interviewer’s Appraisal Sheet (NC 1131/5) 2 required for 2200, 2205, and 22053.
Student programs 22007, 1985, and 1925 on 1 required. (Important see note 2)
022 Employment References DD Form 370 (1 from each employer for the last 3 years, Minimum combined total of 3
including part-time employment) (Important see note 3) valid references required
023 Character References required if employment references are not available
024 Instructor Reference
025 Training Program Director Reference 2200, required when employment references are not available
026 Health Professional Qualification Summary (NC 1131/11) 2200, 2205, and 22001 only
027 Professional Certificate/License 2200, 2205, 22001 and 22053 as applicable, not required for student programs.
028 DEA Certification 2200, 2205 and 22001
029 License Verification (NC 1131/13) all states ever licensed 22001 and 22053
030 Verification Conditions and Release Information (NC 1131/47) 2200/2205 only, signed and dated within 6 months.
031 Evidence of Specialty Training/Specialty Clarification/Specialty Experience 2200 and 2205 only, if applicable
CHECKLIST (Rev 1-08) Page 1 of 2
032 Duty Preference for Medical Programs (NC 1131/16) 2200, 22001, three choices required
033 Critical Skills Accession Bonus (CSAB) Accept / Decline Letter 1985 only
034 Application Letter for Dental Corps Accession Bonus Program 2200 only
035 Application for HPLRP 2200 and 22001, if eligible
# YES N/A PRIOR SERVICE INFORMATION
036 DD 214(s) If prior active service/reserve service
037 Conditional Release (DD 368) Navy Drilling Reserve and all non-Navy military
038 CO’s Recommendation all Active Duty applicants
039 Enlisted Personnel Action Request (NP 1306/7) active duty Navy enlisted only. (Important see note 4)
040 Prior Service Record If prior service. (Important see note 5)
041 Letter of Inter-Service Transfer Request
042 Contingent Resignation Letter if commissioned in another service
043 Verification of Current Grade and Date of Rank statement must come from parent service
044 Verification of no fails to select to next higher paygrade statement must come from parent service
045 Change of Name Statement (NC 1131/14) and provide copy of court documents/marriage license
046 Family Care Plan Certificate (NP 1740/6) must include if single parent or dual military as applicable
047 Dual Compensation & Waiver Claim Statement (NC 1100/26) required if “yes” responses to questions 20a. & 20b.
of Sec I of Application for Commission
048 Police Record Checks (DD 369) Submit if any derogatory information noted on application
049 Maximum Age Statement of Understanding (NC 1131/54)
050 United States Navy Tattoo Screening Certificate (NC 1130/104) if applicable
051 Disclosure of SSN Privacy Act Statement (NC 5211/1)
052 Statement of Understanding for Security Investigation (NC 1070/613)
053 Report of Medical Examination (DD 2808) include all attachments & consults, must have HIV, drug & alcohol test
results DATE of PHYSICAL EXAM Physical must not be older than 2 years.
054 Report of Medical History (DD 2807-1)
055 Privacy Act Statement for Health Care Records (DD 2005)
056 Fingerprint Charts (FD258) Retain at NRD. (Important see note 6)
Signed/Date OPO Signature/Date
Person Completing Checklist
1 Transcripts can be electronic version but must be printed in the Recruiter’s presence and signed/dated by an Officer Recruiter
(in rank of 01 or above) to be a true copy. If classes taken at a prior school are listed with class name and grade on degree
transcript do not need to request that transcript. Cannot just state number or credits/hours transferred.
2 For 2200, 2205, and 22053: At least one (1) interview must be by an officer in same subspecialty for which applying; second
interview may be from any officer (active, reserve or retired).
For 22007, 1985, and 1925i: Only one (1) interview must be by a DC Officer (active, reserve or retired) needed if GPA is equal
to or less than 3.0 and DAT is equal to or less than 20.
Interviews cannot be from anyone in recruiting. General guidance: recommend O-4 or above unless otherwise negotiated with
Specialty Leader/Program Manager. Annotate on NC1131/1 if negotiation made with SL/PM.
3 If full-time employment has been with the military for the past 3 years applicant can use Evals/FITREPS.
4 Active duty applicants applying for program must submit an NP1306, including message release from NPC (requesting
conditional release). Once applicant is final selected, NRD must submit an NP1306 requesting discharge or release from
5 For active duty send only fitreps/evals and any derogatory information.
6 LIVESCAN of applicant fingerprints to be conducted by MEPS at time of physical.
For Official Use Only When Filled In
CHECKLIST (Rev 1-08) Page 2 of 2