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					                                           HANDWRITTEN STATEMENT                                                                 Print Form
                                                       Honor - Courage - Commitment
                                                         PRIVACY ACT STATEMENT
AUTHORITY AND PURPOSE: 5 U.S.C. 301, Departmental Regulations; and E.O. 9397 (SSN). Provided information is used to assist officials and
employees of the Navy in the management, supervision and administration of Navy personnel (officer and enlisted) and the operations of related
personnel affairs and functions.
ROUTINE USES: Information will be utilized by Department of the Navy officials in verifying qualifications and suitability for enlistment.
DISCLOSURE: Disclosure is voluntary; however, failure to provide the requested information as well as the social security number may result in
denial of enlistment into the United States Navy.

Event of Offense                                 Charge if Cited                             City                       State

Name(s) of Police Agency(s)                                                In the Court of

Place of Residence at the Time of Offense                                                    City                       State

Date of the Offense/Charge                                                 Age of Applicant at the Time of Offense/Charge

Outcome, Disposition if Charged and Final Status
                                      Description : Who, What, Where, When, How

I, (Name)                                                              (SSN)                                     do honestly declare that:

        Honor, Courage, Commitment: I affirm that the above statement is true in all respects.

      Applicants Signature                                     Date                 Witness' Signature                             Date

NAVCRUIT 1133/78 (Rev 2-09)               FOR OFFICIAL USE ONLY WHEN FILLED IN