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RTOOLS 51 CH19 Enlistment Kit.xls

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RECRUITER INFORMATION
NRD                                                    NRS                                 STATION ID                     TODAY'S DATE

RECRUITER:                                                                                              RATE                           RANK                          RECRUITER SSN


APPLICANT INFORMATION
A. SERVICE                     D      N            B. PRIOR SERVICE           YES                NO    (1) DIEUS(YYYYMMDD)                           D. SELECT SERVICE                    E.SELECTIVE SERVICE REGISTRATION NUMBER

PROCESSING FOR                       NAVY          C. NUMBER OF DAYS                                   (2) DIERC(YYYYMMDD                            CLASSIFICATION

1. SOCIAL SECURITY NUMBER                                   2. NAME (Last, First, Middle Name, (and Maiden, if any), Jr., Sr., etc.)



3. CURRENT ADDRESS                                                                                                                     4. HOME OF RECORD
(Street, City, County, State, Country, Zip Code)                                                                                       (Street, City, County, State, Country, Zip Code)



CTY                                  COU                    ST          CNT                ZIP                                         CTY                                  COU                    ST           CNT               ZIP

DATES AT THIS ADDRESS(YYYYMM)                                                                                       PHONE #                                         HIGH SCHOOL
FROM                                                              TO
COLLEGE/GRAD YR/CREDITS/MAJOR/GPA                                                                                   ALG I              ALG II                DATES OF SCHOOL ATTENDANCE                                     (YYYY MM)
                                                                                                                                                             FROM                                          TO
5. CITIZENSHIP (X One)                                                                                              6. SEX                                   7.a. RACIAL CATEGORY (X One)
       a. US AT BIRTH (If this box is marked, also X (1) or (2))                                                                a. MALE                      (1) WHITE

              (1) NATIVE BORN                                                                                                   b. FEMALE                    (2) BLACK

              (2) BORN ABROAD OF US PARENT(S)                                                                       8. MARITAL STATUS                        (3) ASIAN/PACIFIC ISLANDER

       b. US NATURALIZED                                                                                            (Specify)                                (4) AMERICAN INDIAN/ALASKAN NATIVE

       c. US NON-CITIZEN NATIONAL                                                                                                                            (5) OTHER (Specify)

       d. IMMIGRANT ALIEN(Specify)                                                                                  9. NUMBER OF                             7.b. ETHNIC CATEGORY (Specify)

                                                                                                                          DEPENDENTS

       e. NON-IMMIGRANT FOREIGN NATIONAL(Specify)                                                                                                            7.c. SPANISH/HISPANIC                                    YES               NO


10. DATE OF BIRTH(YYYYMMDD)                            11. RELIGIOUS PREFERENCE                               12. EDUCATION                                         13. PROFICIENT IN FOREIGN LANGUAGE                            YES         NO
                                                       (Optional)                                             (Years/Highest                                        (If Yes, specify. If No, enter NONE. )
                                                                                                              Grade Compl)                                                                                                  1st         2d
14. VALID DRIVERS LICENSE (X One)                                                                      YES                NO           15. PLACE OF BIRTH (City, State, Country)
(If Yes, list State, Number, and Expiration Date)                                                                                      CTY                                                                      ST

                                                                                                                                       COU                                                                      CNT

16. APTITUDE:                a. ASVAB REQUIRED TO ENLIST?                                              YES         NO                                        d. ENLISTING UNDER STUDENT TEST SCORES                                     YES
                             b. TEST TYPE:         INITIAL                    SPECIAL                  CONFIRMATION                                          e. PREVIOUS DATE(YYYYMMDD):
                             c. RETEST:       1 MONTH                         6 MONTH                  MEPS COMMANDER AUTHORIZED                             f. PREVIOUS TEST VERSION:
       I have never been tested ANYTIME OR ANYWHERE with the Armed Services Vocational Aptitude Battery (ASVAB)                                                                                                 HEIGHT (ACTUAL INCHES)
       I was tested on the ASVAB on or about                                                                                                            at

         EST                  AFQT                                                                           (Most Recent Date Tested)                                          (Place Tested)                  WEIGHT (ACTUAL LBS)
       Request for student test scores (high school look-up)                                                                                            at

                                                                                                             (Most Recent Date Tested)                                                    (Place Tested)
20 MEDICAL:                  a. MEDICAL EXAM REQUIRED TO ENLIST?                                       YES                             NO                    b. DATE LAST FULL EXAM (YYYYMMDD):
                             c. EXAM TYPE:        FULL PHYSICAL                            INSPECTION                     SPECIAL                                   CONSULT                                OTHER

JOB                                                         EMPLOYER/PHONE NUMBER                                                                                                             VOTEC/JOB CORPS


FULL NAME OF FATHER(Last, First, Middle Names)                                                                                   MAIDEN NAME OF MOTHER((Last, First, Middle Names)
FOR USE OF THIS FORM, SEE MEPCOM REG 680-3                                          REQUEST FOR EXAMINATION                                                                                                    FOR OFFICIAL USE ONLY

                                                                              THE INFORMATION PROVIDED CONSTITUTES AN OFFICIAL STATEMENT
                                                                                           PRIVACY ACT STATEMENT
AUTHORITY: Sections 505, 508, 510, and 3012 of Title 10 U.S. Code and Executive Order 9397. PRINCIPAL PURPOSE: To request administration of enlistment aptitude and/or medical qualification
examinations. Social Security Number is used to positively identify examination results. ROUTINE USE: Record is maintained with other enlistment processing records. DISCLOSURE: Voluntary; refusal to
provide required data could result in denial of enlistment.
A. SERVICE PROCESSING FOR             B. PRIOR SERVICE           YES              NO        C. SELECTIVE SERVICE CLASSIFICATION                 D.SELECTIVE SERVICE REGISTRATION NUMBER

        NAVY               D N              NUMBER OF DAYS:
1. SOCIAL SECURITY NUMBER                                           2. NAME (Last, First, Middle Name, (and Maiden, if any), Jr., Sr., etc.)
                     -                  -
3. CURRENT ADDRESS                                                                                                                 4. HOME OF RECORD ADDRESS
   (Street, City, County, State, Country, Zip Code)                                                                                (Street, City, County, State, Country, Zip Code)




5. CITIZENSHIP (X One)                                                                                          6. SEX (X One)                    7.a. RACIAL CATEGORY (X One or more)
        a. US AT BIRTH (If this box is marked, also X (1) or (2))                                                     a. MALE                              (1) AMERICAN INDIAN/                                (4) NATIVE HAWAIIAN OR OTHER

              (1) NATIVE BORN                                                                                         b. FEMALE                                   ALASKAN NATIVE                                     PACIFIC ISLANDER

              (2) BORN ABROAD OF US PARENT(S)                                                                   8. MARITAL STATUS                          (2) ASIAN                                           (5) WHITE
                                                                                                                    (Specify)
        b. US NATURALIZED                                                                                                                                  (3) BLACK OR AFRICAN AMERICAN                       (6) DECLINE TO RESPOND

        c. US NON-CITIZEN NATIONAL                                                                              9. NUMBER OF
        d. IMMIGRANT ALIEN(Specify)                                                                             DEPENDENTS                        7b. ETHNIC CATEGORY (X One)
        e. NON-IMMIGRANT FOREIGN NATIONAL(Specify)                                                                                                          (1) HISPANIC OR                         (1) NOT HISPANIC OR            (3) DECLINE TO

        f. ALIEN REGISTRATION NUMBER (As applicable)                                                                                                            LATINO                                LATINO                             RESPOND

10. DATE OF BIRTH(YYYYMMDD)                        11. RELIGIOUS PREFERENCE (Optional)               12. EDUCATION (Years/Highest Grade Completed)                13. PROFICIENT IN FOREIGN LANGUAGE (X One)                       YES         NO
                                                                                                                                                                  (If Yes, specify)
                                                                                                                                                                                                                             1st         2nd
14. VALID DRIVERS LICENSE (X One)                                   YES                NO                                          15. PLACE OF BIRTH (City, State, Country)
(If Yes, list State, Number and Expiration Date)
16. APTITUDE: a. ASVAB REQUIRED TO ENLIST?                                       c. TEST TYPE                   d. RETEST                                                                e. PREVIOUS TEST VERSION
                    (X One)           [ ]   YES               [ ]    NO                [ ] INITIAL                    [ ]    1ST RETEST           [ ]      6 MONTH RETEST                    1.                 2.

                    b. ENLIST UNDER STUDENT TEST SCORES?                               [ ]   SPECIAL                  [ ]    2ND RETEST                                                  f. PREVIOUS TEST DATES (YYYYMMDD)
                                                                                                                                                                                             1.                  2.
                    (X One)           [ ]   YES               [ ]    NO                [ ] CONFIRMATION               [ ]    IMMED RETEST AUTHORIZED
17. a RECRUITER ID/SSN                                        b. STATION ID                      18. TEST ADMINISTRATOR SSN/ID                             19. TEST ADMINISTRATOR SIGNATURE


20. MEDICAL:              a. MEPS MEDICAL EXAM REQUIRED TO ENLIST?                                   b. EXAM TYPE             [ ] FULL            [ ]      SPECIAL [ ]           RE-EXAM            c. DATE LAST FULL MEDICAL EXAM
                                (X One)            [ ] YES          [ ]    NO                                                [ ]   INSPECT [ ]             CONSULT [ ]           OTHER                  (YYYYMMDD)

21. APPLICANTS SIGNATURE                                                                                                                                   22                                        MIRS CODING
                                                                                                                                                                 WKID             ST         DATE       INT        DATE              INT


23.      APPLICANT CERTIFICATION IN PRESENCE OF TEST ADMINISTRATOR                                                                                                                                  24. RIGHT THUMBPRINT
  I certify that I am the person identified on this form:                                                  Photo ID (X ONE)                       YES                    NO                         RIGHT THUMBPRINT, FIRST ATTEMPT
                                                                                                                                                                                                    (AFFIX THUMBPRINT WITH THUMBNAIL
                                                                                                           If yes, type/organization                                                                POINTED TO THE LEFT)

                                                                                                           ID Number
                          (Signature of Applicant)

25. APPLICANT CERTIFICATION IN PRESENCE OF RECRUITING PERSONNEL
I certify that I am the person identified on this form and that the information about me shown there, including my Social Security Number is all true and correct
to the best of my knowledge. I also certify that:
   a.               I have never been tested ANYTIME OR ANYWHERE with the (ASVAB) either for enlistment purposes or as a student under the ASVAB testing program.

  b.                I was tested on the ASVAB on or about                                                                            at
                                                                                             (Most Recent Date Tested)                                   (School, City, and State)
   c.               Request for student test scores (high school look-up)                                                            at
                                                                                  (Most Recent Date Tested)                                              (School, City, and State)
  d.                Yes, I want to keep my AFQT scores from the student test listed in "c" above.
                                                                                                                                                                                                    IF SECOND ATTEMPT IS REQUIRED,
   e. Current or last high school attended                                                             /
                                                                                                                                                                                                    TURN FORM OVER (TOP OF FORM ON
                                                                    (High School)                    OR                                   (13 Digit Code)
                                                                                                                                                                                                    THE BOTTOM) AFFIX RIGHT
   f.                                                                                                                                                                                               THUMBPRINT ON UPPER RIGHT
                                   (Signature of Applicant)                                                  (Social Security Number)                                           (Date)              CORNER, THUMBNAIL POINTED TO THE
                                                                                                                                                                                                    LEFT

MEDICAL RECORDS RELEASE AUTHORITY: I request and authorize individuals/organizations listed below to release to the MEPS a complete transcript of my medical records. This release is for the purpose of further evaluation
of my medical acceptability under military medical fitness standards. The medical records are to be obtained by the examinee at no cost to the Government and made available for review during the pre-enlistment physical.

26. APPLICANTS CURRENT MEDICAL INSURER NAME                                                                           27. APPLICANTS CURRENT MEDICAL PROVIDER NAME
        (If none, sign your complete name to affirm that you have no current medical insurer):                               (if none, sign your complete name to affirm that you have no current medical provider):



28. MEDICAL INSURER ADDRESS                                                                                           32. MEDICAL PROVIDER ADDRESS
        (Street, City, State, Country, Zip Code)                                                                             (Street, City, State, Country, Zip Code)



30. CERTIFICATION BY RECRUITING PERSONNEL                                                                                                                                                                        APPLICANT SSN
I certify that I have properly identified this applicant in accordance with my service directives, have reviewed for completeness and accuracy the
information provided on this form, and have witnessed the applicants signature.
                                                              /                                                                                      /
   (Signature. of Recruiter (or rep if auth))                              (Printed/Typed Name of Recruiter/or Rep)                                                    (Date)

                   (Printed/Typed Name of Recruiter (if not recorded above))


(Recruiter ID/SSN)                                                                     (Local Recruiting Activity)                                (Bn, NRD, Sq or RS Location)

USMEPCOM Form 680-3A-E, DEC 03                                                                                                                                                                           Previous editions are obsolete.
                                                ENLISTMENT STATEMENT OF UNDERSTANDING
APPLICANTS SHALL ACKNOWLEDGE EACH RELEVANT ENTRY BY PLACING INITIALS BY THE ENTRY. THE ORIGINAL SHALL BE PLACED IN THE
SERVICE RECORD, ONE COPY SHALL BE PROVIDED TO THE ENLISTEE AND ONE COPY SHALL BE PLACED IN THE RESIDUAL FILE.
1. MONTGOMERY GI BILL (MGIB) I am eligible for the MGIB if this is my initial entry onto active duty. I understand that I am automatically enrolled
and my pay will be reduced by $ 100 for the first full 12 months of active duty. I will have ONLY ONE opportunity to disenroll upon arrival at
recruit/officer training, or at the activity where first gained active duty. If I disenroll, I cannot re-enroll later. If I remain enrolled, I cannot SUSPEND
or STOP my pay reduction and there is NO REFUND of my monies. MGIB benefits and further eligibility criteria will be discussed in detail
when I report for active duty.
                                         (initials)

2. MOVIE ACKNOWLEDGMENT. I have reviewed the following movies:                                "Recruit Training -The Journey Begins"
"Zero Tolerance"                    "Mutual Respect"                     "Drug Testing in Navy Boot Camp"                                (initials)
                     (initials)                        (initials)                                                     (initials)

3. SWIM QUALS AT RTC. I certify that I know how to swim or will learn to swim. I understand, failure to achieve water survival qualifications will
result in assignment to intensive swim remedial training for up to three weeks. Failure of remedial training may result in loss of guaranteed program.


 (initials)

4. (FEMALES ONLY). I understand that I will receive a pregnancy test within 72 hours upon arrival at RTC.
                                                                                                                                       (initials)

5. NAVY PHYSICAL READINESS PROGRAM. I understand I must at all times maintain Navy physical readiness standards and that personnel who fail
to do so cannot advance in paygrade, reenlist or transfer. I understand that I must maintain a percent body fat value of 22% or less for males or
33% or less for females to be eligible to ship to RTC.
                                                                    (initials)

6. DRUG USAGE. DRUG USAGE IN THE NAVY IS PROHIBITED AND WILL NOT BE TOLERATED! I understand that urinalysis testing will take place
within 72 hours upon arrival at RTC. If I test positive, I will be discharged based upon fraudulent enlistment. Alcohol abuse or illegal
or improper use of drugs during my enlistment could result in possible administrative separation with less than an honorable discharge and loss of
veterans benefits.
                            (initials)

7. SUPPORT OF EQUAL PROTECTION AND CIVIL LIBERTY GUARANTEES OF THE CONSTITUTION: I understand that my oath of enlistment requires
me to uphold and defend the Constitution of the United States, which guarantees the civil rights and equal protection under the law for all residents
of the United States. I further understand that Navy and Department of Defense directives prohibit participation of military personnel in extremist or
supremacist activities or organizations that attempt to deprive individuals of their civil rights. Failure to comply with these prohibitions may result in
disciplinary action under the Uniform Code of Military Justice.
                                                                                 (initials)

8. DIRECT DEPOSIT SYSTEM (DDS). I have been briefed on the contents of SECNAVINST 7200.17 and understand the requirement that I enroll in
the DDS. I understand that failure to perform the duty of establishing and maintaining a DDS account, in the absence of a specific exemption, may
subject me to administrative and/or disciplinary action under the Uniform Code of Military Justice.
                                                                                                                         (initials)

9. ADVANCED PAYGRADE ACKNOWLEDGMENT. I have been briefed by recruiting personnel on how I might be/become eligible for enlistment in an
advance paygrade. I understand that it is my responsibility to obtain required documentation of participation in youth programs and/or post high
school education prior to the date I am to report for active duty. I understand that my eligibility for all advanced paygrade programs terminates with
graduation from recruit training, with the exception of advancement for referrals which ends upon arrival at my first permanent duty station.


 (initials)




                        SIGNATURE OF APPLICANT (DATE)                                                          SIGNATURE OF NRD PERSONNEL (DATE)




                                  TYPE OR PRINT NAME                                                               TYPE OR PRINT NRD PERSONNEL
NAVCRUIT 1133/53 (Rev. 2-00)
                                          ENLISTMENT STATEMENT OF UNDERSTANDING
                                                 REGARDING FAMILY MEMBERS
APPLICANTS SHALL ACKNOWLEDGE EACH RELEVANT ENTRY BY PLACING INITIALS BY THE ENTRY. THE ORIGINAL SHALL BE PLACED IN THE
SERVICE RECORD, ONE COPY SHALL BE PROVIDED TO THE ENLISTEE AND ONE COPY SHALL BE PLACED IN THE RESIDUAL FILE.
1. I understand that if I am/become married and my spouse is serving in any branch of the armed forces no promises or guarantees can be made
regarding assignment with or near my spouse.                             (initials)


2. I understand that if I now have or later have children, I must ensure that care of my children does not interfere with performance of my duties.
If my child/children is/are currently in the custody of another adult pursuant to a court-ordered transfer, I understand that I may not regain custody or have
the child/children reside with me during the term of my first enlistment. I understand that duty assignments are based on the needs of
the Navy and no preferential treatment is granted to members with families. I understand that inability to perform my duties, repetitive absenteeism, or
non-availability for world-wide assignment because I cannot arrange child care during my required absences for duty may result in disciplinary action
and involuntary separtion from the Navy.                    (initials)


3. I understand that should I in the future regain custody or have my child/children reside with me, I understand that government-funded transportation
will not be provided for my child/children. I further understand that should my child/children reside with me in the future while I am a single parent or am
married to an active duty member, I would be required to complete a Dependent Care Certificate and comply with the requirements of OPNAVINST 1740.4.
Failure to do so may result in disciplinary action and my involuntary separation for the convenience of the government on the basis of parenthood.
             (initials)


4. I understand that if I now have or later have children, I have a moral and legal obligation to provide support at all times for my children. I understand
that I must provide proof of dependency status prior to obtaining dependent allowances. I understand that government family housing is often not
available.                   (initials)


5. I understand that if I now have or later have children and am a single parent, or my spouse is on active duty, I must complete a Dependent Care
Certificate and comply with the requirements of OPNAVINST 1740.4. Failure to do so may result in disciplinary action and involuntary separation for the
convenience of the government on the basis of parenthood.                             (initials)




                          SIGNATURE OF APPLICANT (DATE)                                             SIGNATURE OF NRD PERSONNEL (DATE)



                      TYPE OR PRINT APPLICANT'S NAME                                                TYPE OR PRINT NRD PERSONNEL NAME




NAVCRUIT 1133/71 (06/03)
                         RECORD OF MILITARY PROCESSING - ARMED FORCES OF THE UNITED STATES                                                                                                                                 Form Approved
                                                                                                                                                                                                                           OMB No. 0704-0173
                                               (Read Privacy Act Statement and Instructions on back before completing this form)                                                                                           Expires OCT 31, 2006
The public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to
Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports (0704-0173), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302. Respondents should be aware
that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS.
A. SERVICE                                     B. PRIOR SERVICE:                                   C. SELECTIVE SERVICE CLASSIFICATION                                       D. SELECTIVE REGISTRATION NO.
   PROCESSING FOR                                   YES                         NO

        NAVY              D N
                                               NUMBER OF DAYS:

                                                                                                         SECTION I - PERSONAL DATA
1. SOCIAL SECURITY NUMBER                                             2. NAME (Last, First, Middle Name (and Maiden, if any), Jr., Sr., etc)
                     -                    -
3. CURRENT ADDRESS                                                                -                                    4. HOME OF RECORD ADDRESS                                                                               -
      (Street, City, County,                                                                                                (Street, City, County, State,
        State, Country, ZIP Code)                                                                                             Country, ZIP Code)




5. CITIZENSHIP (X one)                                                                                       6. SEX (X one)                     7.a. RACIAL CATEGORY (X one or more)                                       7.b. ETHNIC
                                                                                                                                                                                               (4) NATIVE HAWAIIAN OR            CATEGORY
        a. U.S. AT BIRTH (If this box is marked, also X (1) or(2))                                               a. MALE                              (1) AMERICAN INDIAN/
                                                                                                                                                                                               OTHER PACIFIC ISLANDER
             (1) NATIVE BORN                        (2)    BORN ABROAD OF U.S. PARENT(S)                         b. FEMALE                                   ALASKA NAVTIVE                                                         (1) HISPANIC OR
                                                                                                                                                                                                                                        LATINO
        b. U.S. NATURALIZED                                                                                                                           (2) ASIAN                                                                     (2) NOT HISPANIC OR
                                                                                                                                                                                               (5) WHITE
                                                                                                                                                                                                                                        LATINO
                                                                                                                                                      (3) BLACK OR AFRICAN                                                          (3) DECLINE TO
        c. U.S. NON-CITIZEN NATIONAL                                                                                                                                                           (6) DECLINE TO RESPOND
                                                                                                                                                      AMERICAN                                                                          RESPOND
        d. IMMIGRANT ALIEN (Specify)                                                                         8. MARITAL STATUS (Specify)                                                9. NUMBER OF DEPENDENTS
        e. NON-IMMIGRANT FOREIGN NATIONAL (Specify)

        ALIEN REGISTRATION NUMBER (If issued)

        _________________________________

10. DATE OF BIRTH                                   11. RELIGIOUS                                            12. EDUCATION                                   13. PROFICIENT IN FOREIGN                                                       1st        2nd
                                                                                                                (Yrs/Highest Ed                                  LANGUAGE(If Yes, specify.
        (YYYYMMDD)                                        PREFERENCE                  (Optional)
                                                                                                                  Gr Completed)                                   If No, enter NONE.)


14. VALID DRIVER'S LICENSE (X One)                                              YES                NO                  15. PLACE OF BIRTH (City, State, Country)
        (If Yes, list State, number and expiration date)



                                                          SECTION II - EXAMINATION AND ENTRANCE DATA PROCESSING CODES
                                                           (FOR OFFICE USE ONLY - DO NOT WRITE IN THIS SECTION - Go on to page 2, Question 20.)
16. APTITUDE TEST RESULTS
a. TEST ID         b. TEST SCORES                                                                                      GS            AR         WK           PC        MK        EI            AS               MC         AO           VE
                                                           AFQT
                                                           PERCENTILE
17. DEP ENLISTMENT DATA
a. DATE OF DEP ENLISTMENT (YYYYMMDD)                             b. PROJ ACTIVE DUTY DATE (YYYYMMDD)                                 c. ES                             d. RECRUITER IDENTIFICATION                                 e. PROGRAM
                                                                                                                                                                                                                                        ENLISTED FOR


f. T-E MOS/AFS                 g. WAIVER            (2)               (3)                   (4)                  (5)                 (6)              h. PAY GRADE
                               (1)


18. ACCESSION DATA
a. ENLISTMENT DATE              (YYYYMMDD)                 b. ACTIVE DUTY SERVICE DATE (YYYYMMDD)                             c. PAY ENTRY DATE (YYYYMMDD)                       d. TOE




e. WAIVER          (2)                (3)                  (4)                  (5)                (6)                 f. PAY GRADE             g.DATE OF GRADE(YYYYMMDD)                      h. ES                               i. YRS. /HIGHEST ED
(1)                                                                                                                                                                                                                                     GR COMPL


j. RECRUITER IDENTIFICATION                                      k. PROGRAM                        I. T-E MOS/AFS                    m. PMOS/AFS                  n. YOUTH       o. OA         p. TRANSFER TO (UIC)
                                                                    ENLISTED FOR


19. SERVICE                                     1         2       3         4         5      6           7       8      9        10        11    12         13    14     15      16       17     18        19        20   21       22    23        24     25
    REQUIRED
    CODES                                     26     27          28   29          30       31      32          33      34       35         36   37      38        39    40     41       42      43     44        45       46       47   48         49    50

  51        52     53     54         55       56      57         58   59          60       61      62          63      64       65         66   67      68        69    70     71       72      73     74        75       76       77   78         79    80

 81         82     83 84             85       86      87         88   89          90       91      92          93      94       95         96   97      98        99 100 101 102 103 104 105 106 107 108 109 110

111 112 113 114 115                           116 117 118 119 120 121 122 123 124 125                                                  126 127 128 129 130 131 132 133 134 135 136 137 138 139 140




DD FORM 1966/1, NOV 2003 (RTools)                                                           PREVIOUS EDITIONS ARE OBSOLETE
                                                     PRIVACY ACT STATEMENT

        AUTHORITY: Title 10 USC Sections 504, 505, 508, 12102, 520a; Title 14 USC Sections 351
        and 632; Title 50 USC Appendix 451; and EO 9397

        PRINCIPAL PURPOSE(S): DD Form 1966 is the basic form used by all the Military Services and the
        Coast Guard for obtaining data used in determining eligibility of applicants and for establishing
        records for those applicants who are accepted.

        ROUTINE USE(S): None.

        DISCLOSURE: Voluntary; however, failure to answer all questions on this form, except questions
        labeled as "Optional," may result in denial of your enlistment application.




                                                                 WARNING


             Information provided by you on this form is FOR OFFICIAL USE ONLY and will be maintained and used in
        strict compliance with Federal Laws and regulations. The information provided by you becomes the property of
        the United States Government, and it may be consulted throughout your military service career, particularly
        whenever either favorable or adverse administrative or disciplinary actions related to you are involved.




        YOU CAN BE PUNISHED BY FINE, IMPRISONMENT OR BOTH IF YOU ARE FOUND GUILTY OF
        MAKING A KNOWING AND WILLFUL FALSE STATEMENT ON THIS DOCUMENT.




                                                             INSTRUCTIONS

                                                 (Read carefully BEFORE filling out this form.)


        1. Read Privacy Act Statement above before completing form.

        2. Type or print LEGIBLY all answers. If the answer is "None" or "Not Applicable," so state.
        "Optional" questions may be left blank.

        3. Unless otherwise specified, write all dates as 8 digits (with no spaces or marks) in YYYYMMDD
        fashion. June 1, 2000 is written 20000601.




DD FORM 1966/1, NOV 2003 (RTools)                                                                             Back of Page 1
                     RECORD OF MILITARY PROCESSING - ARMED FORCES OF THE UNITED STATES                                                                                                 Form Approved
                                                                                                                                                                                       OMB No. 0704-0173
                                         (Read Privacy Act Statement and Instructions on back before completing this form)                                                             Expires Oct 31, 2006
The public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection                           of
information, including suggestions for reducing the burden, to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports (0704-0173),
1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any                          penalty for
failing to comply with a collection of information if it does not display a currently valid OMB control number.
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS.
A. SERVICE            B. PRIOR SERVICE:       C. SELECTIVE SERVICE CLASSIFICATION                                                                                          D. SELECTIVE REGISTRATION NO.
   PROCESSING FOR        YES          NO

        NAVY              D N
                                            NUMBER OF DAYS:

                                                                                                    SECTION I - PERSONAL DATA
1. SOCIAL SECURITY NUMBER                                             2. NAME (Last, First, Middle Name (and Maiden, if any), Jr., Sr., etc)
                     -                 -
3. CURRENT ADDRESS                                                            -                                      4. HOME OF RECORD ADDRESS                                                                        -
      (Street, City, County,                                                                                              (Street, City, County, State,
        State, Country, ZIP Code)                                                                                           Country, ZIP Code)




5. CITIZENSHIP (X one)                                                                                   6. SEX (X one)                      7.a. RACIAL CATEGORY (X one or more)                                 7.b. ETHNIC
                                                                                                                                                                                           (4) NATIVE HAWAIIAN          CATEGORY
        a. U.S. AT BIRTH (If this box is marked, also X (1) or(2))                                             a. MALE                             (1) AMERICAN INDIAN/
                                                                                                                                                                                           OR OTHER PACIFIC
                                                 (2)       BORN ABROAD OF U.S. PARENT(S)                                                                  ALASKA NAVTIVE                   ISLANDER                        (1) HISPANIC OR
             (1) NATIVE BORN                                                                                   b. FEMALE
                                                                                                                                                                                                                               LATINO
        b. U.S. NATURALIZED                                                                                                                        (2) ASIAN                                                               (2) NOT HISPANIC OR
                                                                                                                                                                                           (5) WHITE
                                                                                                                                                                                                                               LATINO
                                                                                                                                                   (3) BLACK OR AFRICAN                    (6) DECLINE TO                  (3) DECLINE TO
        c. U.S. NON-CITIZEN NATIONAL
                                                                                                                                                   AMERICAN                                RESPOND                             RESPOND
        d. IMMIGRANT ALIEN (Specify)                                                                     8. MARITAL STATUS (Specify)                                                  9. NUMBER OF DEPENDENTS
        e. NON-IMMIGRANT FOREIGN NATIONAL (Specify)

         ALIEN REGISTRATION NUMBER (If issued)

         ___________________________________

10. DATE OF BIRTH                                11. RELIGIOUS                                           12. EDUCATION                                    13. PROFICIENT IN FOREIGN                                                 1st        2nd
                                                                                                               (Yrs/Highest Ed                                LANGUAGE(If Yes, specify.
        (YYYYMMDD)                                         PREFERENCE                 (Optional)
                                                                                                                 Gr Completed)                                  If No, enter NONE.)


14. VALID DRIVER'S LICENSE (X One)                                          YES                    NO                15. PLACE OF BIRTH (City, State, Country)
        (If Yes, list State, number and expiration date)



                                                  SECTION II - EXAMINATION AND ENTRANCE DATA PROCESSING CODES
                                                   (FOR OFFICE USE ONLY - DO NOT WRITE IN THIS SECTION - Go on to page 2, Question 20.)
16. APTITUDE TEST RESULTS
a. TEST ID         b. TEST SCORES                                                                                    GS          AR          WK           PC        MK          EI         AS          MC         AO           VE
                                                           AFQT
                                                           PERCENTILE
17. DEP ENLISTMENT DATA
a. DATE OF DEP ENLISTMENT (YYYYMMDD)                             b. PROJ ACTIVE DUTY DATE (YYYYMMDD)                             c. ES                              d. RECRUITER IDENTIFICATION                           e. PROGRAM
                                                                                                                                                                                                                               ENLISTED FOR


f. T-E MOS/AFS                 g. WAIVER         (2)                  (3)                    (4)               (5)               (6)               h. PAY GRADE
                               (1)


18. ACCESSION DATA
a. ENLISTMENT DATE              (YYYYMMDD)                 b. ACTIVE DUTY SERVICE DATE (YYYYMMDD)                           c. PAY ENTRY DATE (YYYYMMDD)                        d. TOE




e. WAIVER          (2)                (3)                  (4)              (5)                    (6)               f. PAY GRADE            g. DATE OF GRADE (YYYYMMDD)                   h. ES                          i. YRS. /HIGHEST ED

(1)                                                                                                                                                                                                                            GR COMPL



j. RECRUITER IDENTIFICATION                                      k. PROGRAM                        I. T-E MOS/AFS                m. PMOS/AFS                    n. YOUTH        o. OA      p. TRANSFER TO (UIC)
                                                                    ENLISTED FOR


19. SERVICE                                  1         2         3     4          5        6        7      8         9      10      11     12      13      14      15      16        17   18     19     20       21       22     23       24      25
    REQUIRED
    CODES                                   26   27          28      29     30          31         32    33      34       35       36     37      38      39      40     41      42       43    44     45        46       47    48        49     50

  51        52     53     54     55         56   57          58      59     60          61         62    63      64       65       66     67      68      69      70     71      72       73    74     75        76       77    78        79     80

 81         82     83 84         85         86   87          88      89     90          91         92    93      94       95       96     97      98      99 100 101 102 103 104 105 106 107 108 109 110

111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140

19a. DEP/ACCESSION RECORD (TO BE COMPLETED BY MEPS PERSONNEL)
                   WRK AND STATUS CODE                                            DATE OF ACTION                          Q/C                      WRK AND STATUS CODE                                  DATE OF ACTION                          Q/C




DD FORM 1966/1 (ADP), NOV 2003 (RTools)                                                             PREVIOUS EDITIONS ARE OBSOLETE
20. NAME (Last, First, Middle Initial)                                                                   21. SOCIAL SECURITY NUMBER


                                                          SECTION III - OTHER PERSONAL DATA
22. EDUCATION
 a. List all high schools and colleges attended.      (List dates in YYYYMM format.)                                                       (5) GRADUATE
(1) FROM                 (2) TO                  (3) NAME OF SCHOOL                            (4) LOCATION                                   YES    NO




                                                                                                                                               YES     NO

  b. Have your ever been enrolled in ROTC, Junior ROTC, Sea Cadet Program or Civil Air Patrol?

23. MARITAL/DEPENDENCY STATUS AND FAMILY DATA
      (If "Yes," explain in Section VI, "Remarks")

  a. Is anyone dependent upon you for support?

  b. Is there any court order or judgment in effect that directs you to provide alimony or support for children?

  c. 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?


  d. Are you the only living child in your immediate family?

24. PREVIOUS MILITARY SERVICE OR EMPLOYMENT WITH THE U.S. GOVERNMENT
      (If "Yes," explain in Section VI, "Remarks.")

  a. Are you now or have you ever been in any regular or reserve branch or the Armed Forces or in the Army National Guard
     or Air National Guard?


  b. Have you ever been rejected for enlistment, reenlistment, or induction by any branch of the Armed Forces of the United
     States?


  c. Are you now or have you ever been a deserter from any branch of the Armed Forces of the United States?

  d. Have you ever been employed by the United States Government?


  e. Are you now drawing, or do you have an application pending, or approval for: retired pay, disability allowance, severance
     pay, or a pension from any agency of the government of the United States?

25. ABILITY TO PERFORM MILITARY DUTIES
      (If "Yes," explain in Section VI, "Remarks.")

  a. 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?)


  b. Have you ever been discharged by any branch of the Armed Forces of the United States for reasons pertaining to being a
     conscientious objector?


  c. 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)?

26. DRUG USE AND ABUSE (If "Yes," explain in Section VI, "Remarks.")
     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?
DD FORM 1966/2, NOV 2003 (RTools)                                                                                                                    Page 2
27. NAME (Last, First, Middle Initial)                                                                                   28. SOCIAL SECURITY NUMBER


                                                                        SECTION IV - CERTIFICATION
29. CERTIFICATION OF APPLICANT                 (Your signature in this block must be witnessed by your recruiter.)
  a. I certify that the information given by me in this document is true, complete, and correct to the best of my
     knowledge and belief. I understand that I am being accepted for enlistment based on the information
     provided by me in this document; that if any of the information is knowingly false or incorrect, I could be
     tried in a civilian or military court and could receive a less that honorable discharge which could affect my
     future employment opportunities.
  b. TYPED OR PRINTED NAME               (Last, First, Middle        c. SIGNATURE                                                          d. DATE SIGNED(YYYYMMDD)
      Initial)


30. DATA VERIFICATION BY RECRUITER (Enter description of the actual documents used to verify the following items.)
  a. NAME (X one)                                                     b. AGE (X one)                                         c. CITIZENSHIP (X one)
      (1) BIRTH CERTIFICATE                                                 (1) BIRTH CERTIFICATE                                (1) BIRTH CERTIFICATE
      (2) OTHER (Explain)                                                   (2) OTHER (Explain)                                  (2) OTHER (Explain)
 d. SOCIAL SECURITY NUMBER (SSN) (X one)                               e. EDUCATION (X one)                                   f. OTHER DOCUMENTS USED
      (1) SSN CARD                                                          (1) DIPLOMA
      (2) OTHER (Explain)                                                   (2) OTHER (Explain)
31. CERTIFICATION OF WITNESS
a. I certify that I have witnessed the applicant's signature above and that I have verified the data in the documents required as prescribed by
my directives. I further certify that I have not made any promises or guarantees other than those listed and signed by me. I understand my
liability to trial by courts-martial under the Uniform Code of Military Justice should I effect or cause to be effected the enlistment of anyone
known by me to be ineligible for enlistment.
b. TYPED OR PRINTED NAME (Last, First,                  c. PAY              d. RECRUITER I.D.                 e. SIGNATURE                            f. DATE SIGNED
    Middle Initial)                                        GRADE                                                                                         (YYYYMMDD)



32. SPECIFIC OPTION/PROGRAM ENLISTED FOR, MILITARY SKILL, OR ASSIGNMENT TO A GEOGRAPHICAL AREA GUARANTEES
a. SPECIFIC OPTION/PROGRAM ENLISTED FOR (Completed by Guidance Counselor, MEPS Liaison NCO, etc., as specified by sponsoring service.)
    (Use clear text English)



                                                                                                                                                      c. APPLICANT'S
b. I fully understand that I will not be guaranteed any specific military skill or assignment to a geographic area except as shown in
                                                                                                                                                         INITIALS
Item 32.a. above and annexes attached to my Enlistment/Reenlistment Document (DD Form 4).

33. CERTIFICATION OF RECRUITER OR ACCEPTOR
a. I certify that I have reviewed all information contained in this document and, to the best of my judgment and belief, the applicant fulfills
all legal policy requirements for enlistment. I accept him/her for enlistment on behalf of the United States (Enter Branch of Service)
                      NAVY                       and certify that I have not made any promises or guarantees other than those listed in item 32.a.
above. I further certify that service regulations governing such enlistments have been strictly complied with and any waivers required to
effect applicant's enlistment have been secured and are attached to this document.
b. TYPED OR PRINTED NAME (Last, First,                  c. PAY              d. RECRUITER I.D. OR e. SIGNATURE                                         f. DATE SIGNED
    Middle Initial)                                        GRADE               ORGANIZATION                                                              (YYYYMMDD)



                                                                      SECTION V - RECERTIFICATION
34. RECERTIFICATION BY APPLICANT AND CORRECTION OF DATA AT THE TIME OF ACTIVE DUTY ENTRY

a. I have reviewed all information contained in this document this date. That information is still correct and true to the best of my knowledge
and belief. If changes were required, the original entry has been marked "See Item 34" and the correct information is provided below.
b. ITEM NUMBER                 c. CHANGE REQUIRED




d. APPLICANT                                                                       e. WITNESS
(1) SIGNATURE                                    (2) DATE SIGNED (1) TYPED OR PRINTED NAME (Last,                        (2) RANK/    (3) SIGNATURE
                                                         (YYYYMMDD)              First, Middle Initial)                      GRADE


DD FORM 1966/3, NOV 2003 (RTools)                                                                                                                                     Page 3
35. NAME (Last, First, Middle Initial)                                                                          36. SOCIAL SECURITY NUMBER


                                                                    SECTION VI - REMARKS
                                         (Specify items(s) being continued by item number. Continue on separate pages if necessary.)




                                                                                                                                       DD FORM 1966/5     YES

                                                                                                                                       ATTACHED?(X one)   NO

                                   SECTION VII - STATEMENT OF NAME FOR OFFICIAL MILITARY RECORDS
37. NAME CHANGE.
     If the preferred enlistment name (name given in item 2) is not the same as on your birth certificate, and it has not been changed by legal procedure
prescribed by state law, and it is the same as on your social security number card, complete the following:

 a. NAME AS SHOWN ON BIRTH CERTIFICATE                                               b. NAME AS SHOWN ON SOCIAL SECURITY NUMBER CARD




 c. I hereby state that I have not changed my name through any court or other legal procedure; that I prefer to use the name of
                                                                               by which I am known in the community as a matter of convenience
    and with no criminal intent. I further state that I am the same person as the person whose name is shown in Item 2.
d. APPLICANT
(1) SIGNATURE                                                                                                                          (2) DATE SIGNED
                                                                                                                                          (YYYYMMDD)


E. WITNESS
1. TYPED OR PRINTED NAME (Last, First, Middle Initial)             (2) PAY GRADE               (3) SIGNATURE


DD FORM 1966/4, NOV 2003 (RTools)                                                                                                                         Page 4
37. NAME (Last, First, Middle Initial)                                                  37. SOCIAL SECURITY NUMBER


           USE THIS DD FROM 1966 PAGE ONLY IF EITHER SECTION APPLIES TO THE APPLICANT'S RECORD OF MILITARY PROCESSING
                                         SECTION VIII - PARENTAL/ GUARDIAN CONSENT FOR ENLISTMENT
37. PARENT/GUARDIAN STATEMENT(S) (Line out portions not applicable)

     a. I/we certify that (Enter name of applicant)

     has no other legal guardian other than me/us and I/we consent to his/her enlistment in the United States
     (Enter Branch of Service)
                                                                          NAVY

     I/we acknowledge/understand that he/she may be required upon order to serve in combat or other hazardous
     situations. I/we certify that no promises of any kind have been made to me/us concerning assignment to duty,
     training, or promotion during his/her enlistment as an inducement to me/us to sign this consent. I/we hereby
     authorize the Armed Forces representatives concerned to perform medical examinations, other examinations
     required, and to conduct records checks to determine his/her eligibility. I/we relinquish all claim to his/her
     service and to any wage of compensation for such service. I/we authorize him/her to be transported
     unsupervised to/from the Military Entrance Processing Station via public conveyance and to stay unsupervised at
     a government contracted hotel facility.



     b. FOR ENLISTMENT IN A RESERVE COMPONENT


        I/we understand that, as a member of the reserve component, he/she must serve minimum periods of active
     duty for training unless excused by competant authority. In the event he/she fails to fulfill the obligations of
     his/her reserve enlistment, sh/she may be recalled to active duty as prescribed by law. I/we further understand
     that while he/she is in the ready reserve, he/she may be ordered to extended active duty in time of war or
     national emergency declared by Congress or the President or when otherwise authorized by law, and may be
     required upon order to serve in combat or other hazardous situations.



c. PARENT
(1) TYPED OR PRINTED NAME (Last, First, Middle Initial)               (2) SIGNATURE                             (3) DATE SIGNED
                                                                                                                   (YYYYMMDD)


d. WITNESS
(1) TYPED OR PRINTED NAME (Last, First, Middle Initial)               (2) SIGNATURE                             (3) DATE SIGNED
                                                                                                                   (YYYYMMDD)


e. PARENT
(1) TYPED OR PRINTED NAME (Last, First, Middle Initial)               (2) SIGNATURE                             (3) DATE SIGNED
                                                                                                                   (YYYYMMDD)


f. WITNESS
(1) TYPED OR PRINTED NAME (Last, First, Middle Initial)               (2) SIGNATURE                             (3) DATE SIGNED
                                                                                                                   (YYYYMMDD)



40. VERIFICATION OF SINGLE SIGNATURE CONSENT




DD Form 1966/5, NOV 2003 (RTools)                                                                                           Page 5
                                                 WAIVERS HANDWRITTEN STATEMENT


                 NAVY                                    Event or Offense, Charge if Cited.
             HONOR                                       City and State of Offense/Charge. City:                                        State:
             COURAGE                                   Names of Police Agency and Court.
             COMMITMENT                Place of Residence at the Time of Offense/Charge. City:                                          State:
                                 Dates of Offense/Charge & Age of Applicant at the Time. Date:                                           Age:
  Outcome, Disposition if Charged, and Final Status(e.g. fine, probation, repeat course).


             Description (BAC, MPH, etc….), nature of the offense, degree of participation, approximate dollar value for items or property
             and bond posted, sentence, fines & court costs, probation or community service ordered, or reason for poor grades.


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




                               HONOR, COURAGE, COMMITMENT: I affirm that the above statement is true in all respects.



                            Applicant's Signature                               Date                              Witness's Signature


NAVCRUIT 1133/78                                                                                   Continue on additional sheets as required
                                                                                                                               1. DATE OF REQUEST                               Form Approved OMB
                                   POLICE RECORD CHECK                                                                                                                          No. 0704-0007 Expires
                                                                                                                                                                                Oct 31, 2006
The public reporting burden for this collection of information is estimated to average 27 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing
this burden, to Department of Defense, Washington Headquarters Services, Directorate of Information Operations and Reports (0704-0007), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302 .
Respondents should be aware that not withstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid
OMB control number.
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS . RETURN COMPLETED FORM TO ADDRESS SHOWN AT BOTTOM OF FORM.


SECTION I - (To be completed by Recruiting Service)
2. NAME OF APPLICANT (Last, First, Middle Name(s), Alias)                               3. SEX                     4. PLACE OF BIRTH
                                                                                                MALE               a. CITY                                    b. COUNTY                           c. STATE
                                                                                                FEMALE
5. DATE OF BIRTH                  6.a. RACIAL CATEGORY (X one or more)                                                                    b. ETHNIC CATEGORY                                 7. SOCIAL SECURITY
   (YYYYMMDD)                             (1) AMER. INDIAN/ALASKAN NATIVE                       (4) WHITE                                         (1) HISPANIC OR LATINO                        NUMBER
                                          (2) ASIAN                                             (5) NATIVE HAWAIIAN OR OTHER
                                                                                                                                                  (2) NOT HISPANIC OR LATINO
                                                                                                PACIFIC ISLANDER
                                          (3) BLACK OR AFRICAN AMERICAN                         (6) DECLINE TO RESPOND                            (3) DECLINE TO RESPOND

8. ADDRESS IN ADDRESSEE'S JURISDICTION (See "MAIL TO" Block)                                                                                                  9. DATES RESIDED AT THIS ADDRESS
a. NUMBER & STREET (Include aprtment no.)                    b. CITY                                               c. STATE          d. ZIP CODE              a. FROM                       b. TO
                                                                                                                                                                    (YYYYMMDD)                    (YYYYMMDD)


10. PERSON MAKING THIS REQUEST
a. NAME (Last, First, Middle Name(s))                        b. RANK                    c. SIGNATURE                                                          d. TITLE




SECTION II - (To be completed by Applicant)
                                                                                        PRIVACY ACT STATEMENT
AUTHORITY: Title 10 United States Code, Sections 504, 505, 508, 520(a), and 12102; E.O. 9397
PRINCIPAL PURPOSE: To determine eligibility of a prospective enlistee in the Armed Forces of the United States.
ROUTINE USES: Information collected on this form may be released to law enforcement agencies engaged in the investigation or prosecution of a
criminal act or the enforcement or implementation of a statute, rule, regulation or order; to any component of the Department of Justice for the
purpose of representing the DoD.
DISCLOSURE: Voluntary; however, failure of the applicant to complete Section II may result in refusal of enlistment in the Armed Forces of the
United States.
The data are for OFFICIAL USE ONLY and will be maintained and used in strict confidence in accordance with Federal law and regulations. Making a
knowing and willful false statement on this DD Form 369 may be punishable by fine or imprisonment or both. All information provided by you which
possibly may reflect adversely on your past conduct and performance, may have an adverse impact on you in your military career in situations such
as consideration for special assignment, security clearances, court martial and administrative proceedings, etc.
11. I HEREBY CONSENT TO RELEASE FROM YOUR                                                                     SIGNATURE
   FILES THE INFORMATION REQUESTED BELOW.
SECTION III - (To be completed by Police or Juvenile Agency)
The person described above, who claims to have resided at the address shown above has applied for enlistment in the Armed Forces of the United
States. Please furnish from your files the information relative to Section III below. A return envelope is provided for you convenience.
12. HAS THE APPLICANT A POLICE OR JUVENILE RECORD, TO INCLUDE MINOR TRAFFIC VIOLATIONS?                                                                                               YES                     NO
    (If YES, what was the offense or charge, date, disposition and sentence?)




13. IS THE APPLICANT NOW UNDERGOING COURT ACTION OF ANY KIND? (If YES, give details.)                                                                                                 YES                     NO




THIS IS TO CERTIFY THAT THE ABOVE DATA AS CORRECTED ARE TRUE AND CORRECT ACCORDING TO THE RECORD ON FILE IN
THIS OFFICE. THIS INFORMATION IS CONFIDENTIAL AND CANNOT BE USED IN ANY OTHER MANNER EXCEPT FOR OFFICIAL PURPOSES.
14. DATE(YYYYMMDD)                15. TITLE                                                              16. VERIFIED BY (Signature)



LAW ENFORCEMENT AGENCY                                                                                   RECRUITING AGENCY
  MAIL TO:                                                                                                 MAIL FROM:




DD FORM 369, NOV 2003                                                        PREVIOUS EDITION IS OBSOLETE.
                                                                                                                                                                            Form Approved
                                                         REQUEST FOR REFERENCE                                                                                              OMB No. 0704-0167
                                                                                                                                                                            Expires Nov 30, 2004
The public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to Department of Defense, Washington Headquarters Services, Directorate of Information Operations and Reports (0704-0007), 1215 Jefferson Davis
Highway, Suite 1204, Arlington, VA 22202-4302 . Respondents should be aware that not withstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a
collection of information if it does not display a currently valid OMB control number.
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS. RETURN COMPLETED FORM TO THE ADDRESS SHOWN BELOW.

                                                                                   PRIVACY ACT STATEMENT

   AUTHORITY: 10 U.S.C. 503, 504, 505, 508, 510; and E.O. 9397.                                          ROUTINE USE(S): None.

   PRINCIPAL PURPOSE(S): This form is mailed to an applicant's                                           DISCLOSURE: Voluntary; however, failure to furnish requested
   employer, former employer, or school official, to solicit information                                 information may result in a negative determination in the matter of
   needed to determine the applicant's suitability for service in the                                    your request for service in the Armed Forces of the United States
   Armed Forces of the United States.




   TO:                                                                                                               Your timely reply will help the defense effort. Please
                                                                                                                     fill out and return promptly. A return envelope, which
                                                                                                                     requires no postage, is enclosed for your
                                                                                                                     convenience.



                                                                              APPLICANT IDENTIFICATION DATA

1. NAME (Last, First, middle Initial)                                                                            2. MAILING ADDRESS (Street, Apartment Number, City, State, and
                                                                                                                      ZIP Code)

3. DATE OF BIRTH (YYYYMMDD)                           4. SOCIAL SECURITY NUMBER


5. DATES OF SCHOOL ATTENDANCE OR EMPLOYMENT
a. FROM (YYYYMMDD)                                    b. TO (YYYYMMDD)




        The above-named person has made an application for                                                  Enlistees who cannot adjust satisfactorily to military life must be
    enlistment in the Armed Service and has given your name as a                                         discharged, causing emotional distress to the individual, as well as
    reference. The information you provide will be appreciated since it                                  loss to the tax-payers. Therefore, by giving your frank opinion of
    will assist in determining whether or not the applicant meets the                                    the applicant, you can render a genuine service to the applicant as
    eligibility standards to become a member of the Armed Forces of                                      well as to the United States.
    the United States.
                                                                                                           Your statements will be held in strict confidence, and you will not
        Service standards require that applicants be mature,                                             be considered personally responsible in any way for the applicants
    intelligent, and possess high moral qualifications.           Those                                  conduct if enlisted or not enlisted.
    applicants who are selected will have an opportunity to receive
    schooling and training in technical fields to improve and advance                                       Your answers to the questions listed on the back of this form are
    their knowledge and skills in subjects essential to national                                         of particular interest in reaching a conclusion concerning the
    defense. Additionally, college opportunities will be available.                                      qualifications of the applicant. Any information you can provide will
                                                                                                         be appreciated.




                                                                       RECRUITING OFFICER IDENTIFICATION DATA
6. TYPED NAME (Last, First, Middle Initial)                                               7. DATE SIGNED                             8. UNIT/COMMAND NAME
                                                                                             (YYYYMMDD)


9. SIGNATURE OF RECRUITING REPRESENTATIVE                                                 10. UNIT/COMMAND MAILING ADDRESS (Street, City, State, and Zip Code)




DD FORM 370, JAN 2002                                                         PREVIOUS EDITION IS OBSOLETE
APPLICANT'S NAME: (Last, First, Middle Initial)


11. WHAT IS YOUR RELATIONSHIP TO THE APPLICANT? (Indicate with an "X")
                                                                                 c. OTHER (Specify)
          a. EMPLOYER                            b. SCHOOL OFFICIAL

12. HOW LONG HAVE YOU KNOWN THE APPLICANT?                            13. APPLICANT'S HIGHEST GRADE COMPLETED OR JOB TITLE
   a. FROM (YYYYMMDD)                     b. TO (YYYYMMDD)



14. INCLUSIVE DATES OF SCHOOL ATTENDANCE/                             15. IF APPLICANT LEFT SCHOOL OR JOB, OR WAS EXPELLED, DISMISSED, OR
     EMPLOYMENT IN YOUR SCHOOL OR FIRM.                                   TERMINATED, GIVE SPECIFIC REASON IF KNOWN.
   a. FROM (YYYYMMDD)                     b. TO (YYYYMMDD)



                                                                                                        (Indicate with an "X")
16. HOW DO YOU RATE THE APPLICANT'S:
                                                                         OUTSTANDING              AVERAGE            UNSATISFACTORY          NOT OBSERVED
   a. TRUSTWORTHINESS
   b. ADAPTABILITY
   c. ABILITY TO WORK WELL WITH OTHERS
   d. INITIATIVE
   e. JUDGMENT
   f. PHYSICAL FITNESS
   g. LEADERSHIP
   h. MATURITY
PLEASE ANSWER THE FOLLOWING QUESTIONS TO THE BEST OF YOUR                                                           (Indicate with an "X")
KNOWLEDGE. FOR "YES" ANSWERS, PROVIDE DETAILS IN REMARKS.                                             YES                    NO               UNKNOWN
17. IF THE APPLICANT IS KNOWN TO USE ALCOHOL OR DRUGS, HAS IT AFFECTED
     HIS OR HER JOB PERFORMANCE? (If Yes, explain below)
18. IS THERE ANY REASON WHY YOU WOULD NOT RECOMMEND THIS PERSON
     FOR THE ARMED FORCES? (If Yes, explain below)
19. PLEASE WRITE A PERSONAL NARRATIVE EVALUATION OF THE APPLICANT BELOW, OR ON A PLAIN PIECE OF PAPER, AND
    ATTACH TO THIS FORM.




20. PERSON COMPLETING QUESTIONNAIRE
a. TYPED OR PRINTED NAME (Last, First, Middle Initial)                b. TITLE


c. SIGNATURE                                                                                                       d. DATE SIGNED (YYYYMMDD)




DD FORM 370 (BACK), JAN 2002
                Request for Evaluation of Non-Traditional Education Credentials, and Foreign Education

                 SECTION I: Request for Evaluation of Non-Traditional Education Credentials, and Foreign Education
         If sent out-of-district, request must be initiated by EPO, and must indicate EPO telephone and fax number. If request is for
               pre-ship review of "M" DEPers, original Tier-Level Evaluation must be provided along with financial transcript).

Name of Applicant                                                          SSN:                          Date of Birth:

If foreign Education, name of Country:

NRS:                                  Recruiter:                               Phone:                              Fax:

Date Scheduled for MEPS Processing                                                               AFQT:

Note: Recruiter must ensure that all non-traditional of foreign education credentials are attached to this form and submit for          ESS
review. Documents must be legible and submitted at least 2 days prior to date applicant is scheduled to process at MEPS.

Note for applicant requiring foreign education verification: A complete printed English translation must accompany foreign education
documents in any language other than English.

SECTION II: Education Certification (For Education Services Specialist Use Only)


Date Certified:                                                Case Number (Optional):

Date on Transcript:                                                               Years of Formal Education:

Certified as: (Check One)             NHSDG          HSG          HSDG         Education Code:
(Approval if foreign education verification)                                            (Years and Code)


Advanced Paygrade Eligibility
based on foreign education:              None           E-2          E-3

Certified by:
                                                                 (Signature and location)


Comments:




SECTION III Verification (For Commanding Officer Use for Non-Traditional Education) Any disagreement between the CO
and ESS must be forwarded to CNRC, Code 355, for resolution.



Comments:




CO: Signature & Date
                                                  ENLISTEE FINANCIAL STATEMENT

The public reporting burden for this collection of information is estimated To average 33 minutes per response including the time for reviewing
instructions, searching existing date sources, gathering and maintaining the data needed and completing and reviewing the collection of information.
Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing the burden to
Department of Defense, Washington Headquarters Services, Directorate for information operations and reports (0703-0020), 1215 Jefferson Davis
Highway, Suite 1204, Arlington, VA 22202-4302. Respondents should be aware that not withstanding any other provision of law, no person shall be
subject to any penalty for failing to comply with collection of information if it does not display a currently valid OMB control number
PLEASE DO NOT RETURN YOUR ENLISTEE FINANCIAL STATEMENT TO THE ABOVE ADDRESS.
                                         PRIVACY ACT STATEMENT
AUTHORITY 5 U.S.C. 301 Department Regulations; 10 U.S.C. Sections 503,504,508 and 510 and e.o. 9397
Principal Purpose or Purposes. The information is to determine your eligibility for enlistment in the armed forces of the United States. The information requested
constitutes the minimum required to determine your present financial status. Your answers will be used to determine demonstrated ability to financially manage your
household and whether or not should you be accepted and subsequently enlisted, your military pay and associated benefits would be sufficient to allow you to provide
adequate financial support to your dependents without causing personal hardship. Routine Uses. The information provided by you on this document is FOR OFFICIAL
USE ONLY and will be maintained and used in strict confidence by Navy Officers and employees of the Navy recruiting Command to determine eligibility.
Whether Disclosure is Mandatory or Voluntary and Effect on Individual of Not Providing Information. The information is voluntary, however failure to answer completely
any of the questions or to provide the information requested in this form may result in an inability to fairly evaluate your qualifications for enlistment.
This statement is used only by authorized U.S. Navy personnel and shall be completed by all applicants with dependents enlisting
or reenlisting in the Regular Navy/Navy reserve. It must be completed by the applicant.


Applicants in DEP over 60 days are required to complete an updated statement prior to shipping to RTC
Applicants who acquire dependents while in DEP shall complete this statement prior to shipping to RTC.
The signature of the spouse is mandatory unless the spouse resides outside the local recruiting area.
Comments of recruiting service personnel will NOT be recorded on this form.
1. APPLICANT'S NAME(LAST, FIRST, MI)                              2. SSN:                   3. ELIGIBLE PAYGRADE:                       4.DATE OF STATEMENT
                                                                                                                                        (YYMMDD):
5. APPLICANT'S CURRENT EMPLOYER                                   5a. NET MONTHLY PAY:                        6. NUMBER OF DEPENDENTS (INCLUDE AGES)


7. SPOUSE'S MONTHLY NET PAY                     8. NUMBER OF SPOUSE DEPENDENTS                                9. OTHER APPLICANT/FAMILY INCOME
 (TAKE, HOME):                                    NOT IN ITEM 6:                                                (list source and monthly amount)



10.HOUSING:            OWN         BUYING            RENTING          OTHER EXPLAIN                                      10a. Housing monthly cost: $


11. Do you have a savings account?                   YES              NO               Current Balance: $


   Do you have a checking account?                   YES              NO               Current Balance: $

12. Have you ever filed for bankruptcy?                                                     YES                                         NO If yes, explain
   Have you ever been late on any payment more than 30 days?                                YES                                         NO If yes, explain
   Do you have any liens or judgements pending against you?                                 YES                                         NO If yes, explain

13. MONTHLY NAVY INCOME


      a. Base Pay $                                            b. BAH Allowance $                                                c. Gross Navy Pay $


                   d. Less Deductions (Fed/State Tax, Soc Sec, MGIB & SGLI) $                                                      e. NET Navy Pay $


NAVCRUIT 1130/13 (Rev 1/00)
                                                 ENLISTEE FINANCIAL STATEMENT
14. Monthly Recurring Debt


CATEGORY                                                                                  TOTAL AMOUNT-OWED                          MONTHLY PAYMENT

AUTOMOBILE (1)

CREDIT CARD (1)

CREDIT CARD (2)

CREDIT CARD (3)

CREDIT CARD (4)

CREDIT CARD (5)

BANK LOAN (1)

BANK LOAN (2)

BANK LOAN (2)

CHILD SUPPORT/ALIMONY

OTHER CREDIT DEBT

                                                                                                                                     *14a
                                        TOTAL                                                              $0.00                               $0.00

15. APPLICANTS REMARKS: (if additional space is required, continue on separate sheet of paper.)




16. 1 certify that the information given in this statement is a true account of my financial obligations and that my dependents (line out as
appropriate) DO/DO NOT require any special medical attention/treatment.



                    Signature of Applicant                             (Date)                                Signature of Spouse                       (Date)




                      Authenticating Recruiter (Print Name)                                                 Signature of Recruiter                     (Date)


NAVCRUIT 1130/13 (Rev 1/00)                                                                                                                    Page 2
Monthly Recurring Debt Matrix




NOTE:      Present total monthly payment disclosed in item 14a of Enlisted Financial Statement
           (NAVCRUIT 1130/13) can not exceed the amount listed in the Monthly Recurring
           Debt Matrix. If 14a exceeds the figures listed in the above matrix applicant is
           considered to be at a high risk of experiencing financial difficulties early in his or her
           enlistment and should not be enlisted. Enlistment eligibility determinations for
           applicants exceeding acceptable recurring debt figures in the table above must be
           processed in the following manner:

           1. For applicants with one dependent or enlisting in paygrade E-4 and above, the
           NRD CO or XO will interview and determine enlistment eligibility based on the
           applicant's financial situation and stability.


           2. For applicants enlisting in paygrades E- I through E-3 with more than one
           dependent, CNRC (Code 356) must make enlistment eligibility determinations and
           issue an exception to policy control number. At a minimum the following documents
           must be provided to CNRC (Code 356) for review:

                   a. Waiver Briefing Sheet (NAVCRUIT 1133/39)
                   b. Enlistee Financial Statement (NAVCRUIT II 3 0/13)
                   c. Verification of Spouse's income (W-2 Form, last pay stub)
                   d. An itemized income/expense budget, which estimates the applicant's finances for the up-
                   coming month. (No specific format).




NAVCRUIT 1130/13 (Rev 1/00)                                                                             Page 3
                                          MARRIED APPLICANTS AND SPOUSES FACT SHEET
SHIP DEPLOYMENT/UNDERWAY SCHEDULE. The Navy has dozens of different sizes and types of ships to which you could be assigned. These
range from hydrofoils with crews of 24 to the super carriers with 6,000 people aboard. Your ship will spend much of the time in, or operating near, her
homeport. Ships normally spend about 10 to 14 days at sea per month operating out of their homeports for local training. Homeports may be located in the
United States or overseas.

Normally, your ship will also "deploy" on the average of two or three times in a four year period. Each deployment is approximately six months in duration.
When deployed, your ship may make port calls (visits) to cities in the area of your deployment. Remember, before your ship "deploys", ensure your family
is taken care as far as housing, adequate funds for living expenses, power of attorney, etc. NOTE: Operational commitments can change at any time,
depending upon the situation.

ENLISTED PERSONNEL IN PAYGRADES E-3 AND BELOW WITH DEPENDENTS WILL NOT BE ASSIGNED DUTY IN AN OVERSEAS
AREA, INCLUDING HAWAII, ON AFLOAT UNITS OVERSEAS OR SHORE BASED ACTIVITIES OVERSEAS.

HOUSING. Prior to moving your family members, you should first contact the local Housing Referral Office to obtain information on government and
civilian housing. On most bases, government housing may not be available. If housing is not available, you might be placed on a waiting list, if you desire,
until housing is available. If government housing is available, you will not receive your Basic Allowance for Housing (BAH).

Housing , depending upon the area, can b e very expensive. Monthly rental rates for a one bedroom apartment can range from $160.00 on the low side to as
much as $1300.00 on the high side. Security deposits, which generally equal to one month's rent, are required in advance. This does not include security
deposits on utilities, sewage and water, garbage, cable TV, etc.

The Navy will provide Basic Allowance for Housing (BAH). BAH will normally only cover 75% of your rental rate.

CHILD CARE FACILITIES. If your spouse plans to continue working during your enlistment, the Navy Family Service Center can provide lists of
military and civilian "day care" centers. Depending upon the area you are assigned, "day care" may not be available on some bases.

The cost of military "day care" can range from $169.00 to $351.00 monthly depending upon family income. Child care normally accommodates ages 6
months to 12 years. For "new born" care, you will have to look at civilian day care centers or private day care providers. The cost of "new born" care can
be very expensive, ranging from $100.00 per week to $900.00 per month.

In most "day care" centers you will still have to provide food and whatever else that may be required that the "day care" center does not provide.

MOVING HOUSEHOLD GOODS. Career military service members have a some what of a nomadic lifestyle and over a 20 year career, will move
several times. Even though the government pays for the move, there are still expenses the service member will be required to pay.

The Navy's Personal Property Office will provide information on the requirements to move your household goods. The government has set weight
allowances on household goods. For paygrades E-1 through E-3 (with dependents), you will be allowed to ship 5,000 pounds of household goods.

Service member's weight allowance includes the total weight of the household goods shipped, those put in storage and those sent as unaccompanied
baggage. It is the service member's responsibility to stay within their weights allowances: so a good estimate of the weight of household goods is essential.
Make the first estimate before visiting the transportation office to set up the move. A fairly dependable method for estimating is to figure 1,000 pounds per
room (excluding bathrooms and storage rooms). Then add the estimated weight of the large appliances and items in the garage and storage.

Keep in mind that estimated weights are not official. Actual charges are based on the weight tickets submitted by the carrier. Service members who exceed
their weight limits must reimburse the government for moving the excess weight: this can cost thousands of dollars.

The above information is very general but provides a beginning for understanding the things which will affect you and your family once you enlist. Always
contact the local Navy Housing Office and Family Service Center, where available for the most updated information on the area to which you are being
stationed.




I acknowledge that I have read and understand the Married Applicant and Spouses Fact Sheet, and have discussed areas of concern with my recruiter.




Signature of Applicant                                         Date                            Signature of Recruiter                          Date


Signature of Applicants Spouse                                 Date

Distribution:
(Original shall be retained in the service record, copy to the applicant and to the residual file)
    orts may be located in the


   tely six months in duration.
    loys", ensure your family




   a waiting list, if you desire,


     0.00 on the low side to as




f household goods is essential.
 is to figure 1,000 pounds per


Service members who exceed


    y once you enlist. Always
                                                                                                                 1. DATE OF REQUEST                                    Form approved
                  REQUEST FOR VERIFICATION OF BIRTH                                                                 (YYYYMMDD)                                         OMB No. 0704-0006
                                                                                                                                                                       Expires Nov 30, 2004
Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to Department of Defense, Washington Headquarters Services, Directorate of Information Operations and Reports (0704-0006), 1215 Jefferson Davis Highway,
Suite 1204, Arlington, VA 22202-4302. Respondents should be aware that not withstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection
of information if it does not display a currently valid OMB control number.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THIS ADDRESS. RETURN COMPLETED FORM TO THE ADDRESS LISTED AT THE
BOTTOM OF THE FORM
 SECTION I (Fill in every item in this section)
2. FULL NAME OF CHILD AT TIME OF BIRTH (Last, First, Middle Names)                                                                  3. SEX (X)              4. DATE OF BIRTH
                                                                                                                                            MALE              (YYYYMMDD)

                                                                                                                                            FEMALE
3. PLACE OF BIRTH
a. CITY                                                               b. COUNTY                                                     c. STATE


6. FULL NAME OF FATHER (Last, First, Middle Names)                                                   7. MAIDEN NAME OF MOTHER (Last, First, Middle Names)




8. PERSON MAKING THIS REQUEST
a. NAME (Last, First, Middle Initial)                                 b. RANK/GRADE                  d. SIGNATURE


c. TITLE


 SECTION II (For use of vital statistics only)
9. CORRECTIONS OF ABOVE STATEMENT MADE ACCORDING TO FACTS ON FILE BY:
a. NAME (Last, First, Middle Initial)                                                                b. ORGANIZATION


c. ADDRESS
(1) STREET                                                                                           (2) CITY                                               (3) STATE          (4) ZIP CODE


This is to verify that the above data as corrected are true and correct according to the                         10. CERTIFICATE NUMBER                     11. FILE DATE (YYYYMMDD)
record on file in this office. These data are confidential and cannot be used in any
manner except for official purposes.

12. VERIFIED BY (Signature)                                                                                                                             13. DATE (YYYYMMDD)



DD FORM 372, JAN 2002                                                        Previous editions are obsolete




RETURN TO RECRUITER STATION:
Standard Form 86                                                                                                  Form approved:
Revised September 1995                                                                                            O.M.B. No. 3206-0007
U.S. Office of Personnel Management                                                                               NSN 7540-00-634-4036
5 CFR Parts 731, 732, and 736                                                                                     86-111

                                 UNITED STATES OF AMERICA
                                 AUTHORIZATION FOR RELEASE OF INFORMATION
                  Carefully read this authorization to release information about you, then sign and date it in ink.



I Authorize any investigator, special agent, or other duly accredited representative of the authorized Federal
agency conducting my background investigation, to obtain any information relating to my activities from
individuals, schools, residential management agents, employers, criminal justice agencies, credit bureaus,
consumer reporting agencies, collection agencies, retail business establishments, or other sources of
information. This information may include, but is not limited to my academic, residential, achievement,
performance, attendance, disciplinary, employment history, criminal history record information, and financial and
credit information. I authorize the Federal agency conducting my investigation to disclose the record of my
background investigation to the requesting agency for the purpose of making a determination of suitability or
eligibility for a security clearance.

I Understand that, for financial or lending institutions, medical institutions, hospitals, health care professionals,
and other sources of information, a separate specific release will be needed, and I may be contacted for such
release at a later date. Where a separate release is requested for information relating to mental health treatment
or counseling, the release will contain a list of the specific questions, relevant to the job description, which the
doctor or therapist will be asked.

I Further Authorize any investigator, special agent, or other duly accredited representative of the U.S. Office of
Personnel Management, the Federal Bureau of Investigation, the Department of Defense, the Defense
Investigative Service, and any other authorized Federal agency, to request criminal record information about me
from criminal justice agencies for the purpose of determining my eligibility for access to classified information
and/or for assignment to, or retention in, a sensitive National Security Position, in accordance with 5 U.S.C. 9101.
I understand that I may request a copy of such records as may be available to me under the law.

I Authorize custodians of records and other sources of information pertaining to me to release such information
upon request of the investigator, special agent, or other duly accredited representative of any Federal agency
authorized above regardless of any previous agreement to the contrary.

I Understand that the information released by records custodians and sources of information is for official use by
the Federal Government only for purposes provided in this Standard Form 86, and that it may be redisclosed by
the Federal Government only as authorized by law.

Copies of this authorization that show my signature are as valid as the original release signed by me. This
authorization is valid for five (5) years from the date signed or upon the termination of my affiliation with the
Federal Government, whichever is sooner. Read, sign and date the release on the next page if you answered
“Yes” to question 21.



Signature (Sign in ink)                            Full Name (Type or Print Legibly)                                      Date Signed


Other Names Used                                                                                             Social Security Number


Current Address (Street, City)                                                         State   ZIP Code      Home Telephone Number
                                                                                                             (Include Area Code)


Page 10
Standard Form 86                                                                                                  Form approved:
Revised September 1995                                                                                            O.M.B. No. 3206-0007
U.S. Office of Personnel Management                                                                               NSN 7540-00-634-4036
5 CFR Parts 731, 732, and 736                                                                                     86-111

                                 UNITED STATES OF AMERICA
                             AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
                     Carefully read this authorization to release information about you, then sign and date it in ink.

Instructions for Completing this Release

This is a release for the investigator to ask your health practitioner(s) the three questions below
concerning your mental health consultations. Your signature will allow the practitioner(s) to
answer only these questions.



I am seeking assignment to or retention in a position with the Federal Government which
requires access to classified national security information or special nuclear information or
material. As part of the clearance process, I hereby authorize the investigator, special agent, or
duly accredited representative of the authorized Federal agency conducting my background
investigation, to obtain the following information relating to my mental health consultations:

         Does the person under investigation have a condition or treatment that could impair
         his/her judgment or reliability, particularly in the context of safeguarding classified
         national security information or special nuclear information or material?

         If so, please describe the nature of the condition and the extent and duration of the
         impairment or treatment.

         What is the prognosis?

I understand the information released pursuant to this release is for use by the Federal
Government only for purposes provided in the Standard Form 86 and that it may be redisclosed
by the Government only as authorized by law.

Copies of this authorization that show my signature are as valid as the original release signed
by me. This authorization is valid for 1 year from the date signed or upon termination of my
affiliation with the Federal Government, whichever is sooner.



Signature (Sign in ink)                            Full Name (Type or Print Legibly)                                      Date Signed


Other Names Used                                                                                             Social Security Number


Current Address (Street, City)                                                         State   ZIP Code      Home Telephone Number
                                                                                                             (Include Area Code)


Page 11
     Federal
        from
    bureaus,
           of
achievement,
         and
          my
           or


professionals,
         such
    treatment
          the


           of
     Defense
          me
  information
            .


  information
      agency


           by
           by


        This
         the
    answered
     below
         to




     which
        or
        or
background




    Federal
redisclosed


    signed
        my
                         UNITED STATES NAVY ILLICIT BEHAVIOR SCREENING CERTIFICATE
TYPE/PRINT NAME OF APPLICANT (LAST, FIRST, MIDDLE)                         SSN:




Section I - Privacy Act Statement
Authority. The authority to request this information is contained in sections 504, 505, 510, 511 and 802 of Title 10,
United States Code as amended.
Principal Purpose or Purposes. The information in this document is used to determine your present enlistment and program
eligibility. The information provided by you on this document is FOR OFFICIAL USE ONLY and will be maintained and
 used in strict confidence in accordance with Federal Law and Regulations
Routine Uses. The information provided by you will become a permanent part of your SERVICE RECORD. This information
constitutes the minimum required to determine your present enlistment and program eligibility.
The information provided by you on this document is FOR OFFICIAL USE ONLY and will be maintained and used in strict
confidence in accordance with Federal Law and Regulations.
Whether Disclosure is Mandatory or Voluntary and Effect on Individual for Not Providing Information. The information
requested is of a personal and confidential nature, and you do not have to provide such information unless you voluntarily
wish to enlist in the Armed Forces of the United States. Failure to answer completely any of the questions or to provide
the information requested may result in an inability to fairly evaluate your enlistment and program eligibility and may result in
a subsequent denial for enlistment.

Section II - Definitions.
Alcohol Abuse- The use of alcohol to an extent that is has an adverse effect on the user's health or behavior, family,
community, or the Navy, or leads to unacceptable behavior as evidenced by one or more alcohol induced incidents.
Alcohol/Drug Dependent- Having a psychological and/or physiological reliance on alcohol or drugs resulting from use on a
periodic continuing basis.
Alcohol or Drug Related Offense- Any charge resulting in pre-trial intervention/deferment or a conviction, finding, decision,
sentence, judgment, or disposition by a court of law, competent jurisdiction, or authorized adjudicative authority
other than unconditionally dropped, unconditionally dismissed, or acquitted in which alcohol, drugs, or drug paraphernalia
was a factor.
Depressants- Sedative-hypnotic drugs, including barbiturates (Phenobarbitals, secobarbital), tranquilizers, bensodiazepines
and methaqualone, capable of inducing varying degrees of behavioral depression. Depending on dose, can have sedating,
tranquilizing, hypnotic (sleep) or anesthetizing effect.
Drug Abuse- Illegal or non-medical use or possession of drugs.
Drug Trafficking or Supplying- The wrongful distribution of a controlled substance.
Experimental/Casual use of Marijuana- The illegal or improper use of marijuana for reasons of curiosity, peer pressure or
other similar reasons by an individual who now positively and clearly rejects any further use. Marijuana use for more than a
few times for reasons of a deeper and more continuing nature is not considered experimental or casual usage.
Hallucinogens/Psychedelics- A group of heterogeneous compounds such as LSD, mescaline, peyote, psilocybin,
psychedelic amphetamine variants (STP, MDA) phencyclidine (PCP), with the ability to induce visual, auditory, or other
hallucinations which separate the individual from reality and can cause disturbances in coherency and perception.
Marijuana- Any intoxicating product of the hemp plant, cannabis (including hashish) or any synthesis thereof.
Narcotics- Any opiates, opiate derivatives, or their synthetic equivalents, including morphine, codeine, heroin, methadone,
talwin, percodan, and darvon.
Stimulants- Widely diverse category made up of central nervous system stimulant drugs, including cocaine, amphetamines,
and methamphetamines, that increase the behavioral activity of the individual.




NAVCRUIT Form 1133/65 (Rev.04/00)
                                UNITED STATES NAVY ILLICIT BEHAVIOR SCREENING CERTIFICATE
Type/Print name of Applicant (Last, First, Middle):                        SSN:



Section II - Definitions (Continued):
Aberrant Behavior. Involvement with groups or organizations advocating violence or illegal activities. Participation in such activities,
whether with such qroups or individually.
Racially Biased Group. A group or organization which exhibits a negative disposition and prejudicial attitudes against an entire
class of persons based solely on racial differences.
Gang Related Violence. Violent activity or behavior stemming from involvement in an association with an organized group which
advocates or engages in criminal activity.
Initiation or Acceptance Activities. Behaviors or activities undertaken with the purposes of gaining membership into a group or
organization which advocates violence or illegal activities.
Hate Crimes. Criminal behavior or activities which illegally discriminate on the basis of race, creed, gender or national origin.

Section III-Drug and Alcohol Usage.
                                                                                                                              INITIAL      INITIAL
                                                                                                                                YES          NO
 1. I have used narcotics, hallucinogens/psychedelic drugs within the past year.
 2. I have used narcotics, hallucinogens/psychedelic drugs between one and two years ago.
 3. I have used narcotics, hallucinogens/psychedelic drugs over two years ago.
 4. I have used stimulant or depressant drugs within the past six months.
 5. I have used stimulant or depressant drugs between six months and one year ago
 6. I have used stimulant or depressant drugs over one year ago
 7. I have used stimulant or depressant drugs over two years ago
 8. I have experimentally/ casually used marijuana within the past six months.
 9. I have experimentally/ casually used marijuana over six months ago
10. I have been convicted of one drug abuse offense.
11. I have been convicted of two or more drug abuse offenses.
12. I have been convicted of one alcohol related offense.
13. I have been convicted of two alcohol related offenses while driving a motor vehicle.
14. I have been convicted of three or more alcohol related offenses while driving a motor vehicle.
15. I have been convicted of two or more alcohol related offenses while not driving a motor vehicle.
16. I have been diagnosed as drug or alcohol dependent
17. I have trafficked, supplied, distributed, sold, or transferred a controlled substance for money.
I certify that I have completed this certificate honestly of my own free will, without concealing any information.




    Date                      Applicant Signature




NAVCRUIT Form 1133/65 (Rev. 04/00)                                                                                                   Page 2 of 4
                              UNITED STATES NAVY ILLICIT BEHAVIOR SCREENING CERTIFICATE
   Type/Print Name of Applicant (Last, First, Middle):                       SSN:




                                                                                                                                 INITIAL       INITIAL
   Section IV - Aberrant Behavior                                                                                                 YES           NO
   1. I have been/am now a member or an of an organization that advocated the degradation of
      cultures or human races other than may own.
   2. I have participated in violent acts committed against a person of a different race.


   3. I have been/am now a member of a gang.


   4. I have participated in an initiation to gain acceptance to a group or gang.


   5. I have committed illegal acts to gain acceptance to a group or gang.



   Section IV - Recruiter and Witness Certification.

I certify that the above applicant signed this certificate of their own free will after telling me that their answers are complete and true.




   Date                     Type/Print Recruiter Name                                     Recruiter Signature


   Date                     Type/Print Witness Name                                       Witness Signature




   Section VI - Pre-Service Illicit Behavior Waiver Form


1. Pre-service Alcohol and Drug Abuse waiver for enlistment (BEERS):
   (check one)              REQUIRED                     NOT REQUIRED




   Date                     Type/Print Recruiter Name and SSN                                        Recruiter Signature




2. I (check one)   request          do not request an individual evaluation for Alcohol and Drug Abuse
waiver consideration prior to entering the Delayed Entry Program.




   Date                     Type/Print Applicant Name and SSN                                        Applicant Signature

NAVCRUIT Form 1133/65 (Rev.04/00)                                                                                                       Page 3 or 4

                              UNITED STATES NAVY ILLICIT BEHAVIOR SCREENING CERTIFICATE
Type/Print Name of Applicant (Last, First, middle):                                         SSN:



Section VII - Enlistment Statement of Understanding:
Drug usage in the Navy is prohibited and will not be tolerated! I understand that I must be completely honest in completing this
certificate, and that if I am honest and am accepted into the Navy no punitive action will be taken against me as a result of the
information provided in this certificate. I understand that should I conceal alcohol or drug abuse information and it is discovered
after my enlistment, punitive action may be taken against me based upon the false statements I have made in this certificate.
I understand that urinalysis testing will take place within 72 hours upon arrival at Recruit Training Command and that if I test positive,
I will be discharge based upon fraudulent enlistment. I understand that illegal or improper use or possession of alcohol or
drugs could result in possible administrative separation with less than an honorable discharge and loss of veterans benefits.



    Applicant Signature                                               Date                         MEPS Liaison Petty Officer Signature            Date
Section VIII - Applicant's Recertification of Pre-Service Illicit Behavior
    (To be completed immediately before commencement of active duty in the Regular Navy or Naval Reserve)

1.                       (applicants initials) I have re-read Section VII Enlistment Statement of Understanding and understand that I
will receive a drug test within 72 hours of reporting to Recruit Training Command and that a positive test will result in my being
processed for a discharge.
2. I have re-read Section III - Drug and Alcohol Usage and Section IV - Aberrant Behavior. I certify that I ( check one)
        I have      have not used illegal drugs, abused alcohol, or participated in aberrant behavior since the date I first completed
Sections II through V. I certify that I have completed this certificate honestly, of my own free will, and without concealing
any information. The following additional information is provided concerning additional illicit behavior since the date I first certified
my drug, alcohol usage and aberrant behavior in Sections II through V.


3. I (check one)              request                 do not request an individual evaluation.



    Date                      Applicant Signature                                                                                 Social Security Number

Section IX - MEPS Liaison Petty Officer and Witness Certification
I certify that the above applicant signed this certificate of their own free will after telling me that their answers are complete and true.



    Date                      Type/Print MEPS Liaison Petty Officer Name                                        MEPS Liaison Petty Officer Signature



    Date                      Type/Print Witness Name                                                           Witness Signature



NAVCRUIT Form 1133/65 (Rev. 04/00)                                                                                                              Page 4 of 4
                                             INSTRUCTIONS FOR DD FORM 2807-2,
                                       MEDICAL PRESCREEN OF MEDICAL HISTORY REPORT


 1. This form is to be completed by each individual who requires medical processing in accordance with Army Regulation 40-501
 Chapter 2 standards, or Department of Defense Directive 6130.3, "Physical Standards for Appointment, enlistment, or Induction."
 The form should be completed by the applicant with the assistance of the recruiter, parent(s), or guardian, as needed (see page 2).

 2. This form replaces the existing medical prescreening form (DD Form 2246). The revisions are designed to ensure that medical
 prescreening questions "used by recruiters and by Military Entrance Processing Command are specific, unambiguous and tied
 directly to the types of medical separations most common for recruits during basic training and follow-on training" (per P.L. 105-85,
 Div. A, Title V, S 532).


 3. Use of this form will also facilitate efficient, timely, and accurate medical processing of individuals applying for service in the
 United States Armed Forces or Coast Guard. The form is designed to assist recruiters in the medical pre-screening of applicants.


 4. The individual completing the DD Form 2807-2 will submit the form, at a minimum, 1 processing day in advance to the MEPS projected
 to process the individual. A minimum of 2 processing days in advance is required if support documentation (e.g., pricate physicians
 paperwork, treatment records, etc.) is required to augment the MEPS CMO review.

 EXPLANATION OF CODES.

 Items are followed by numbers that refer to the following:

 (1) If the applicant has been seen by a physician and/or has been hospitalized for the condition, obtain medical documentation with a
 medical release form and submit records to the MEPS Medical Section. After the MEPS Medical Officer reviews the provided
 information, the appropriate recruiting service member will be informed of the examinee's processing status, or if additional record
 review or specialty consultation may be required for further processing or qualification determination.

     a. If the applicant was evaluated and/or treated on an out-patient basis, obtain a copy of actual treatment records of the
   private medical doctor (PMD) or health care provider (HCP), to include (if any):
     - office or clinic assessment and progress notes, including the initial assessment documents, subsequent evaluation
   and treatment documents, and record and date when released from doctor's care to full, unrestricted activity;
     - emergency room (ER) report;
     - study reports (e.g., x-ray report(s), magnetic resonance imaging (MRI) report(s), or Computerized Tomography (CT)
   scan report(s), etc.);
     - procedure reports (e.g., arthroscopy, electroencephalogram (EEG; brain wave test), echocardiogram (ultrasound of the
   heart), etc.);
     - pathology reports (e.g., if tissue specimens taken from the body and sent to lab for microscopic diagnosis, etc.);
     - specialty consultation records (e.g., neurologist, cardiologist, OB/Gynecologist, gastroenterologist, orthopedic
   surgeon, pulmonologist, allergist, etc.).

     b. If the applicant was hospitalized, then obtain a copy of the hospital record, to include (if any): ER report, admission
   history and physical, study reports, procedure reports, operative report (especially necessary for surgery to bone or joint),
   pathology report, specialty consultation reports, and discharge summary.

 (2) If an applicant has been diagnosed or treated since age 12 for any attention disorder (Attention Deficit Disorder (ADD) or Attention Deficit
 Hyperactivity Disorder (ADHD), etc.), academic skills or perceptual defect, or has had an Individual Education Plan (IEP), call the MEPS for
 additional instructions.
 (3) Condition to be discussed with the examining Medical Officer at time of the medical examination.


 (4) Call MEPS Medical Section to discuss examinee's medical history BEFORE sending the individual in for physical examination.

 (5) Send medical reports to MEPS for review before sending applicant for physical ("papers only" medical review), and MEPS Medical
 Section will advise regarding further medical processing. Records pertaining to non-psychiatric diagnoses may be sent to the Medical
 Section of the processing MEPS, with the envelope stating: "CONFIDENTIAL: MEPS MEDICAL SECTION."


 (6) Send all documentation relating to ANY past or present evaluation, treatment or consultation with a psychiatrist, psychologist,
 counselor or therapist, on an inpatient or out-patient basis for any reason, including but not limited to counseling or treatment for
 adjustment or mood disorder, family or marriage problem, depression, treatment or rehabilitation for alcohol, drug or other substance
 abuse, directly from the treating clinician and/or hospital to the MEPS Chief Medical Officer. The envelope must bear the following
 statement: "CONFIDENTIAL: FOR EYES OF THE MEDICAL OFFICER ONLY."

 (7) May require an orthopedic consult, scheduling to be coordinated by the MEPS CMO and Medical Section.


DD FORM 2807-2, OCT 2003 (RTools)                                                                                                  Page 1 of 6 Pages
                                             MEDICAL PRESCREEN OF MEDICAL HISTORY REPORT                                                                                                                      Form Approved
                                                                                                                                                                                                              OMB No. 0704-0413
                                                                                (Chapter #2 Physicals Only)                                                                                                   Expires OCT 31, 2006


The public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to Department of Defense,
Washington Headquarters Services, Directorate for Information Operations and Reports (0704-0413), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302. Respondents should be aware that notwithstanding any other
provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.



PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS. RETURN COMPLETED FORM AS INDICATED ON PAGE 2.
                                                                                                 PRIVACY ACT STATEMENT
AUTHORITY: 10 USC 504, 505, 507, 532, 978, 1201, 1202, and 4346; and E.O. 9397.
PRINCIPAL PURPOSE(S): To obtain medical data for determination of medical fitness for enlistment, induction, appointment and retention for applicants and
members of the Armed Forces. The information will also be used for medical boards and separation of Service members from the Armed Forces.
ROUTINE USE(S): None.
DISCLOSURE: Voluntary; however, failure by an applicant to provide the information may result in delay or possible rejection of the individual's application to enter
the Armed Forces. For an Armed Forces member, failure to provide the information may result in the individual being placed in a non-deployable status.
WARNING: The information you have given constitutes an official statement. Federal law provides severe penalties (up to 5 years confine-
ment or a $10,000 fine or both), to anyone making a false statement. If you are selected for enlistment, commission, or entrance into a
commissioning program based on a false statement, you can be tried by military courts-martial or meet an administrative board for discharge
and could receive a less than honorable discharge that would affect your future.
 1. APPLICANT
 a. LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)                                                                 b. DATE OF BIRTH (YYYYMMDD)                                c. SOCIAL SECURITY NUMBER



 d. HEIGHT                 e. WEIGHT                 f. MAX WEIGHT                    g. SERVICE/COMPONENT                                            REGULAR                     h. DATE SCREENED (YYYYMMDD)

                                                                                           ARMY                   USMC                USCG            RESERVE

                                             lbs.                                          NAVY                   USAF                                NATIONAL GUARD

   2. Mark each item "YES" or "NO". Every item marked "YES" must be fully explained in item 2b.
    a. HAVE YOU EVER HAD OR DO YOU NOW HAVE:                                                       YES        NO                                                                                                            YES        NO
      (1)    Asthma, wheezing, or inhaler use (4)                                                                        (24)      Any other heart problems (4)

      (2)    Dislocated joint, including knee, shoulder, elbow, ankle                                                    (25)      High blood pressure (4)
             or other joint (1)(7)                                                                                       (26)      Discharged from military service for medical reasons (4)
      (3)    Epilepsy, fits, seizures, or convulsions (4)                                                                (27)      Ulcer (stomach, duodenum or other part of intestine) (4)
      (4)    Sleepwalking (4)                                                                                            (28)      Received disability compensation for an injury or other medical
      (5)    Recurrent neck or back pain (4)(1)(7)                                                                                 condition (4)

      (6)    Rheumatic fever (4)                                                                                         (29)      Hepatitis (liver infection or inflammation) (4)
      (7)    Foot pain (3)                                                                                               (30)
                                                                                                                                   Intestinal obstruction (locked bowels) , or any other chronic or recurrent
      (8)    A swollen, painful, or dislocated joint or fluid in a joint                                                           intestinal problem, including small intestine or colon problems, such as
                                                                                                                                   Chron's disease or colitis (4)
             (knee, shoulder, wrist, elbow, etc.) (1)(7)
      (9)    Double vision (4)                                                                                           (31)      Detached retina or surgery for a detached retina (4)
      (10) Periods of unconsciousness (4)                                                                                (32)      Surgery to remove a portion a portion of the intestine (other than the
      (11) Frequent or severe headaches causing loss of time from work or                                                          appendix) (4)
           school or taking medication to prevent frequent or severe
           headaches (4)                                                                                                 (33)      Any other eye condition, injury or surgery (4)
      (12) Wear contact lenses (If so, bring your contact lens kit and solution so                                       (34)      Are you over 40? (If so, call the MEPS for information on special
           you can remove your contact when we test your vision at the MEPS;                                                       requirements for over-40 physicals) (4)
           also, if you have a pair of eyeglasses, bring them with you no matter
           how old they are.)                                                                                            (35)      Gall bladder trouble or gall stones (4)
      (13) Fainting spells or passing out (4)                                                                            (36)      Jaundice (4)
      (14)                                                                                                               (37)      Missing a kidney (4)
             Head injury, including skull fracture, resulting in concussion,
                                                                                                                         (38)      Allergy to common food (milk, bread, eggs, meat, fish or other common
             loss of consciousness, headaches, etc. (4)                                                                            food) (4)
                                                                                                                         (39)      (Females only) An abnormal PAP smear or gynecological problem (4)

      (15) Back surgery (4)
                                                                                                                                   (Males only) Missing a testicle, testicular implant, or undescended
      (16) Seen a psychiatrist, psychologist, social worker, counselor or other                                          (40)
           professional for any reason (inpatient or outpatient) including                                                         testicle (4)
           counseling or treatment for school, adjustment, family, marriage or
           any other problem, to include depression, or treatment for alcohol,
                                                                                                                         (41)      Broken bone requiring surgery to repair (with or without pins,
           drug or substance abuse (6) (2)
      (17) Any of the following diseases:                                                                                          plates, screws or other metal fixation devices used in repair)
             (a)   Eczema (5)                                                                                            (42)      Ruptured or bulging disk in your back or surgery
             (b)   Psoriasis (5)                                                                                                   for a ruptured or bulging disk (4)
             (c)   Atopic dermatitis (5)                                                                                 (43)      Thyroid condition or take medication for your thyroid (4)
      (18) Irregular heartbeat, including abnormally rapid or slow                                                       (44)      Limitation of motion of any joint, including knee, shoulder,
             heart rates (4)                                                                                                       wrist, elbow, hip or other joint (4)(1)(7)
      (19) Allergic to bee, wasp, or other insect stings                                                                 (45)      Drug or alcohol rehab (4)
             (itching/swelling all over and/or get short of breath) (4)                                                  (46)      Kidney, urinary tract or bladder problems, surgery, stones or
      (20) Heart murmur, valve problem or mitral valve prolapse (4)                                                                other urinary tract problems (4)
      (21) Allergic to wool (4)                                                                                          (47)      Sugar, protein or blood in urine (4)
      (22) Heart surgery (4)                                                                                             (48)      Surgery on a bone or joint (knee, shoulder, elbow, wrist, etc.)

      (23) Been rejected for military service (temporary                                                                           including Arthroscopy with normal findings (1)(7)
           or permanent) for medical or other reasons (4)                                                                (49)      Taking any medications (If so, list reason in item 2b.)

DD FORM 2807-2, OCT 2003 (RTools)                                                                                                                                                                             Page 2 of 6 Pages
                                                                                 MEDICAL PRESCREEN
LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)                                                                                   SOCIAL SECURITY NUMBER


2a. (Continued) HAVE YOU EVER HAD OR DO YOU NOW HAVE:                                YES   NO                                                                                  YES     NO
  (50)    Pain or swelling at the site of an old fracture (4)(1)(7)                             (64)   Shoulder, knee, or elbow problem (out of place) (4)(1)(7)
  (51)    Perforated ear drum or tubes in ear drum(s) (4)                                       (65)   Locking of the knee or other joint (4)(1)(7)
  (52)    Anemia (4)                                                                            (66)   Giving way of the knee or other joint (4)(1)(7)

  (53)    Ear surgery, to include mastoidectomy or repair of perforated ear                     (67)   Cataracts or surgery for cataracts (4)
          drum; hearing loss or need/use a hearing aid (4)                                      (68)   Eye surgery, including radial keratotomy, lens implant
                                                                                                       or other eye surgery to improve your vision (4)
  (54)    Night blindness (4)

  (55)    Arthritis (4)

  (56)    Absence or disturbance of the sense of smell (4)                                      (69)   Collapsed lung or other lung condition (4)
  (57)    Absence or removal of the spleen, or rupture or tear of the                           (70)   Bed wetting since age 12 (4)
          spleen without removal (4)                                                            (71)   Evaluation, treatment, or hospitalization for alcohol abuse,

  (58)    Anorexia or other eating disorder (4)                                                        dependence or addiction (4)(6)

  (59)    Cracked or bone fracture(s) (4)                                                       (72)   Taken medication, drugs, or any substance to improve

  (60)    Bursitis (4)                                                                                 attention, behavior, or physical performance (2)(1)(6)

  (61)    Braces (If you wear or are planning on obtaining braces for your                      (73)   Do you smoke? (If yes:)
          teeth, have the orthodontist submit a letter stating that braces will be                     (a) Type              Cigarettes                  Cigars         Smokeless tobacco
          removed before active duty date; release form and sample format                              (b) How many per day?                    (c) Date last used
          can be found in the Recruiter's Medical Guide.)

                                                                                                (73)   Evaluation, treatment, or hospitalization for substance
  (62)    Loss of finger, toe or part thereof (4)                                                      use, abuse, addiction or dependence (including illegal drugs,
  (63)    Loss of the ability to fully flex (bend) or fully extend a finger,                           prescription medications, or other substances)

          toe or other joint (4)(1)(7)                                                          (75)   Any illnesses, surgery, or hospitalization not listed above
b. EXPLAIN ALL "YES" ANSWERS TO QUESTIONS (1) - (74) ABOVE. (Describe answer(s), give date(s) of problems, name doctor(s), clinic(s), hospital(s),

   treatment given and current medical status. Attach additional sheet(s) if necessary.)




DD FORM 2807-2, OCT 2003 (RTools)                                                                                                                                      Page 3 of 6 Pages
                                                                            MEDICAL PRESCREEN
LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)                                                                              SOCIAL SECURITY NUMBER


b. EXPLAIN ALL "YES" ANSWERS TO QUESTIONS (1) - (74) ABOVE. (Continued)




3. CURRENT PRIMARY CARE PHYSICIAN(S)/PRACTITIONER(S) AND/OR CLINIC(S) (Attach additional sheet(s) if necessary.)
a. NAME(S)                                                                b. ADDRESS (Include ZIP Code)                                    c. TELEPHONE (Include Area Code)




 ------------------------------------------------------------- ---------------------------------------------------------- -------------------------------


4. PREVIOUS PRIMARY CARE PHYSICIAN(S)
a. NAME(S)                                                                b. ADDRESS (Include ZIP Code)
                                                                                                                                           c. TELEPHONE (Include Area Code)


 ------------------------------------------------------------- ---------------------------------------------------------- -------------------------------


5. CURRENT INSURANCE PROVIDER
a. NAME(S)                                                                b. ADDRESS (Include ZIP Code)                                    c. INSURANCE ID NUMBER




 ------------------------------------------------------------- ---------------------------------------------------------- -------------------------------


6. PREVIOUS INSURANCE PROVIDER(S)
a. NAME(S)                                                                b. ADDRESS (Include ZIP Code)                                    c. INSURANCE ID NUMBER




 ------------------------------------------------------------- ---------------------------------------------------------- -------------------------------


                                 STOP AND READ: THE FOLLOWING STATEMENTS APPLY TO SIGNATURES AT ITEMS 7 AND 8

         I certify the information on this form is true and complete to the best of my knowledge and belief, and no person has
          advised me to conceal or falsify any information about my physical and mental history.
         I further understand that I may be requested to provide medical documentation regarding issues within my medical history.
         I authorize any of the doctors, hospitals, clinics or insurance company(ies) to furnish the Department of Defense medical
          authority a complete transcript of my medical record for purposes of processing my application for military service.

7. APPLICANT
a. SIGNATURE                                                                                                                               b. DATE SIGNED
                                                                                                                                             (YYYYMMDD)




8. PARENT OF GUARDIAN SIGNATURE FOR MINOR (Mandatory ) OR PARENT ASSISTING TO COMPLETE FORM (Voluntary )
a. NAME ( Last, First, Middle Initial)                                                  b. SIGNATURE                                       c. DATE SIGNED
                                                                                                                                             (YYYYMMDD)




9. RECRUITING REPRESENTATIVE: I certify all information is complete and true to the best of my knowledge. I have conducted the medical
     prescreening requirements as directed by service regulations.
a. NAME (If representative was used)                                 b. PAY GRADE       c. SIGNATURE                                       d. DATE SIGNED
    (Last, First, Middle Initial )                                                                                                           (YYYYMMDD)




DD FORM 2807-2, NOV 2003 (RTools)                                                                                                                       Page 4 of 6 Pages
                                                                            MEDICAL PRESCREEN
LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)                                                                                         SOCIAL SECURITY NUMBER


10. PHYSICIAN'S SUMMARY AND ELABORATION OF ALL PERTINENT DATA (Physician shall comment on all positive answers in questions (1) - (74).
    Physician may develop by interview any additional medical history deemed important, and record any significant findings here.)

a. COMMENTS




11. MEDICAL OFFICER'S PRESCREENING COMMENTS: Based on information provided, further processing is :

  a. ON PRESCREEN:
       (1) AUTHORIZED                       (2) NOT JUSTIFIED (Permanent Disqualification (PDQ)):                        (3) DEFERRED (See Comments above):

                                                    (a) Profile Serial                      ICD                                  (a) Pending review of additional documentation
                                                    (a) Process for Waiver (CMO initials)                                        (b) RJ Date (If applicable)          (CMO initials)


       (1) APPROVED                         (2) DEFERRED:/                       (a) Additional information needed (See DD Form 2808)                           (4) MEPS USE:
                                            (3) NOT JUSTIFIED                    (b) Information different than on prescreen                                          (a) AE           (c) PRI
                                                                                 (c) Form not prescreened by MEPS                                                     (b) RE           (d) N/A
c. TYPED OR PRINTED NAME OF EXAMINER                           c. SIGNATURE                                                      d. DATE SIGNED                12. NUMBER OF
                                                                                                                                     (YYYYMMDD)                  ATTACHED SHEETS




DD FORM 2807-2, NOV 2003 (RTools)                                                                                                                                      Page 5 of 6 Pages
                                                   MEDICAL PRESCREEN
LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)                       SOCIAL SECURITY NUMBER


13. COMMENTS (Continued)




DD FORM 2807-2, NOV 2003 (RTools)                                                               Page 6 of 6 Pages
                       PRE-ACCESSION DRUG SCREENING ACKNOWLEDGEMENT
  1.   I understand the Navy's pre-accession drug screening program is mandatory and that
       I will be required to participate in one or more drug screenings prior to my
       entering active duty. I have been informed and understand:

       a. Participation is mandatory and refusal to participate will result in my entry
          level separation from naval service.
       b. I will be required to participate in a more thorough drug screening normally
          within 24-hours of my arrival at Recruit Training Center (RTC), Great Lakes.
       c. Should I test "positive" for drugs at RTC, I understand that I will be
          discharged regardless of any "negative" indication for the presence of drugs
          based on any pre‑accession drug‑screening test.
  2.   The Navy's pre-accession drug screening is conducted by the use of a                  non-
       instrumented drug test (NIDT) kit, which will be used to detect the presence
       of marijuana, or marijuana and cocaine within urine specimens. I understand the
       following procedures must be adhered to:

       a. I will be required to use the specimen cup provided to collect an adequate
          sample of my urine. This sample collection will be conducted in a designated
          restroom facility and will be observed by a Navy representative of the same
          sex.
       b. I will be required to test my sample with a NIDT kit supplied by a Navy
          representative in accordance with manufacturer's instructions.
       c. I must dispose of my urine sample and specimen collection cup in accordance
          with instructions provided by the Navy representative.
       d. I will verify test results with the Navy representative assisting me based on
          prescribed manufacturer's instructions.
  3.   If my test indicates a "negative" indication for the presence of marijuana or cocaine,
       I will be permitted to access onto active duty provided I remain   qualified and meet
       all other eligibility requirements.

  4.   I have been informed and understand that one or more of the following administrative
       actions will be required if my NIDT test indicates a "positive" indication for the
       presence of marijuana or cocaine:

       a. Positive for cocaine: Requires mandatory discharge and a waiting period of one
          year before reprocessing for Navy enlistment.
       b. Positive for marijuana (THC):
            (1)I must have my current accession date delayed (usually a minimum of 45
               days).
            (2)I must be reevaluated for continued eligibility for the program(s) in which
               I enlisted, to include any enlistment bonus or other guarantee(s), and that
               I will be informed if I am no longer eligible or have any change in status
               for any program or guarantee. I understand I may be required to reclassify
               into another program should I be found no longer eligible for the program
               in which I enlisted.
            (3)In any case, the Navy may elect to discharge me in accordance with
               regulations.
       c. If I have not used drugs and desire to contest a NIDT positive result, I may
          request an immediate NIDT confirmation test.
  5.   I have received a verbal briefing concerning the Navy's pre-accession drug   screening
       program and I have read and understand the contents of this document. I furthermore
       elect to consent        , or not to consent         to participate. (Enter initials to
       indicate response)

  Name:                                              SSN:
            (Print full name)

  Signature:                                                Date:

NAVCRUIT 1130/23 (Rev. 11/00)

				
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