Congratulations on making the ... -...

Congratulations on making the decision to join the Air Force Reserve!

This is the Forms Pack, by the end of the process you will have completed and submitted the majority of these forms. Please start by opening the OA CHECKLIST FOLDER to the left.

Click on the little paper clip to open attachments then click on the form you need.

The checklist will guide you in what you need to complete to join the AF Reserve!

Please refer back to our website www.militaryrecruiter.us for instructions on proceeding.

PLEASE REMEMBER TO SEND ALL FORMS BACK THROUGH AMRDEC SAFE SITE

RECORD OF EMERGENCY DATA

5 USC 552, 10 USC 655, 1475 to 1480 and 2771, 38 USC 1970, 44 USC 3101, and EO 9397 (SSN). This form is used by military personnel and Department of Defense civilian and contractor personnel, collectively referred toas civilians, when applicable. , it is used to designate beneficiaries for certain benefits in the event of the Service member'sdeath. It is also a guide for disposition of that member's pay and allowances if captured, missing or interned. It also shows names and addresses ofthe person(s) the Service member desires to be notified in case of emergency or death. , it is used to expedite the notificationprocess in the event of an emergency and/or the death of the member. The purpose of soliciting the SSN is to provide positive identification. All itemsmay not be applicable. None. Voluntary; however, failure to provide accurate personal identifier information and other solicited information will delay notification andthe processing of benefits to designated beneficiaries if applicable.

AUTHORITY:PRIVACY ACT STATEMENT

PRINCIPAL PURPOSES:For military personnel

ROUTINE USES:DISCLOSURE:

For civilian personnel

This extremely important form is to be used by you to show the names andaddresses of your spouse, children, parents, and any other person(s) youwould like notified if you become a casualty (other family members or fiance),and, to designate beneficiaries for certain benefits if you die. IT IS YOURRESPONSIBILITY to keep your Record of Emergency Data up to dateto show your desires as to beneficiaries to receive certain death payments,and to show changes in your family or other personnel listed; for example, asresult of marriage, civil court action, death, or address change

INSTRUCTIONS TO SERVICE MEMBER

This extremely important form is to be used by you to show thenames and addresses of your spouse, children, parents, and anyother person(s) you would like notified if you become a casualty.Not every item on this form is applicable to you.

It does not have a legal impacton other forms you may have completed with the DoD or youremployer.

INSTRUCTIONS TO CIVILIANS

IMPORTANT: This form is divided into two sections: Section 1 - Emergency Contact Information and Section 2 - Benefits RelatedInformation. READ THE INSTRUCTIONS ON PAGE 3 BEFORE COMPLETING THIS FORM.

SECTION 1 - EMERGENCY CONTACT INFORMATION

1. NAME (Last, First, Middle Initial) 2. SSN

3a. SERVICE/CIVILIAN CATEGORY b. REPORTING UNIT CODE/DUTY STATION

CIVILIAN CONTRACTOR

This form is usedby the Department of Defense (DoD) to expedite notification inthe case of emergencies or death.

ARMY NAVY MARINE CORPS DoD

4a. SPOUSE NAME (If applicable) (Last, First, Middle Initial) b. ADDRESS AND TELEPHONE NUMBER(Include ZIP Code)

SINGLE DIVORCED WIDOWED

5. CHILDRENa. NAME (Last, First, Middle) b. RELATIONSHIP c. DATE OF BIRTH

(YYYYMMDD) d. ADDRESS AND TELEPHONE NUMBER(Include ZIP Code)

6a. FATHER NAME (Last, First, Middle)

(Last, First, Middle)

b. ADDRESS AND TELEPHONE NUMBER(Include ZIP Code)

7a. MOTHER NAME b. ADDRESS AND TELEPHONE NUMBER(Include ZIP Code)

8a. DO NOT NOTIFY DUE TO ILL HEALTH

10. CONTRACTING AGENCY AND TELEPHONE NUMBER

9a. DESIGNATED PERSON(S)

b. NOTIFY INSTEAD

b. ADDRESS AND TELEPHONE NUMBER(Include ZIP Code) (Military Only)

(Contractors Only)

DD FORM 93, JAN 2008

AIR FORCE

PREVIOUS EDITION IS OBSOLETE

SECTION 2 - BENEFITS RELATED INFORMATION

11a. BENEFICIARY(IES) FOR DEATH GRATUITY c. ADDRESS AND TELEPHONE NUMBER(Include ZIP Code)



(Include rank, rate, (Include rank, rate, or grade

12a. BENEFICIARY(IES) FOR UNPAID PAY/ALLOWANCES NAME AND RELATIONSHIP(Military Only)

13a. PERSON AUTHORIZED TO DIRECT DISPOSITION (PADD) NAME AND RELATIONSHIP(Military Only)

b. RELATIONSHIP d. PERCENTAGE

c. PERCENTAGE

14. CONTINUATION/REMARKS

15. SIGNATURE OF SERVICE MEMBER/CIVILIAN 16. SIGNATURE OF WITNESS 17. DATE SIGNEDor grade if applicable) as appropriate) (YYYYMMDD)

DD FORM 93 (BACK) JAN 2008

(Military Only)

INSTRUCTIONS FOR PREPARING DD FORM 93(See appropriate Service Directives for supplemental instructions for completion of this form at other than MEPS)

All entries explained below are for electronic or typewritercompletion, except those specifically noted. If a computeror typewriter is not available, print in black or blue-black inkinsuring a legible image on all copies. Include "Jr.," "Sr.,""III" or similar designation for each name, if applicable.When an address is entered, include the appropriate ZIPcode. If the member cannot provide a current address,indicate "unknown" in the appropriate item. Addressesshown as P.O. Box Numbers or RFD numbers shouldindicate in Item 15, "Continuations/Remarks", a streetaddress or general guidance to reach the place ofresidence. In addition, the notation "See Item 14" should beincluded in the item pertaining to the particular next of kin orwhen the space for a particular item is insufficient. If theaddress for the person in the item has been shown in apreceding item, it is unnecessary to repeat the address;however, the name must be entered. Those items that areconsidered not applicable to civilians will be left blank.

ITEM 1. Enter full last name, first name, and middle initial

ITEM 2. Enter social security number (SSN)

ITEM 8. Persons Not to be Notified Due to Ill Health.a. List relationship, e.g., "Mother," of person(s) listed inItems 4, 5, 6, or 7 who are not to be notified of a casualtydue to ill health. If more than one child, specify, e.g.,"daughter Susan." Otherwise, enter "None".b. List relationship, e.g., "Father" or name and address ofperson(s) to be notified in lieu of person(s) listed in item 8a.If "None" is entered in Item 8a, leave blank.

ITEM 3a. Service. Military: Mark X in appropriate block.Civilian: Mark two blocks as appropriate. Examples: anArmy civilian would mark Army and either Civilian orContractor; a DoD civilian, without affiliation to one of theMilitary Services, would mark DoD and then either Civilian orContractor as appropriate.

ITEM 3b. Reporting Unit Code/Duty Station. See ServiceDirectives.

ITEM 4a. Spouse Name. Enter last name (if different fromItem 1), first name and middle initial on the line provided. Ifsingle, divorced, or widowed, mark appropriate block.

ITEM 4b. Address and Telephone Number. Enter the"actual" address and telephone number, not the mailingaddress. Include civilian title or military rank and service ifapplicable. If one of the blocks in 4a is marked, leave blank.

ITEM 5a-d. Children. Enter last name (only if different fromItem 1) first name and middle initial, relationship, and date ofbirth of all children. If none, so state. Include illegitimatechildren if acknowledged by member or paternity/maternityhas been judicially decreed. Relationship examples: son,daughter, stepson or daughter, adopted son or daughter orward. Date of birth example: 19950704. For children notliving with the member's current spouse, include addressand name and relationship of person with whom residing initem 5d.

DD FORM 93 (INSTRUCTIONS), JAN 2008

ITEM 6a. Father Name. Last name, first name and middleinitial.

ITEM 6b. Address and Telephone Number of Father. Ifunknown or deceased, so state. Include civilian title ormilitary rank and service if applicable. If other than naturalfather is listed, indicate relationship.

ITEM 7a. Mother Name. Last name, first name and middleinitial.

ITEM 7b. Address and Telephone Number of Mother. Ifunknown or deceased, so state. Include civilian title ormilitary rank and service if applicable. If other than naturalmother is listed, indicate relationship.

ITEM 9a. This item will be used to record the name of theperson or persons, if any, other than the member's primarynext of kin or immediate family, to whom information on thewhereabouts and status of the member shall be provided ifthe member is placed in a missing status. Reference 10USC, Section 655. NOT APPLICABLE to civilians.

ITEM 9b. Address and telephone number of DesignatedPerson(s). NOT APPLICABLE to civilians.

ITEM 10. Contracting Agency and Telephone Number(Contractors only). NOT APPLICABLE to militarypersonnel. Civilian contractors will provide the name oftheir contracting agency and its telephone number.Example: XYZ Electric, (703) 555-5689. The telephonenumber should be to the company or corporation'spersonnel or human resources office.

ITEM 11a. Beneficiary(ies) for Death Gratuity (Militaryonly). Enter first name(s), middle initial, and last name(s)of the person(s) to receive death gratuity pay. A membermay designate one or more persons to receive all or aportion of the death gratuity pay. The designation of aperson to receive a portion of the amount shall indicate thepercentage of the amount, to be specified only in 10 percentincrements, that the person may receive. If the memberdoes not wish to designate a beneficiary for the payment ofdeath gratuity, enter "None," or if the full amount is notdesignated, the payment or balance will be paid as follows:

(1) To the surviving spouse of the person, if any;(2) To any surviving children of the person and thedescendants of any deceased children by representation;(3) To the surviving parents or the survivor of them;(4) To the duly appointed executor or administrator of theestate of the person;(5) If there are none of the above, to other next of kin of theperson entitled under the laws of domicile of the person atthe time of the person's death.

The member should make specific designations, as itexpedites payment.

Military:

INSTRUCTIONS FOR PREPARING DD FORM 93(Continued)

DD FORM 93, JAN 2008

ITEM 11a. (Continued) Seek legal advice if naming a minorchild as a beneficiary. If a member has a spouse butdesignates a person other than the spouse to receive all or aportion of the death gratuity pay, the Service concerned isrequired to provide notice of the designation to the spouse.NOT APPLICABLE to civilians.

Item 11b. Relationship. NOT APPLICABLE to civilians.

ITEM 11c. Enter beneficiary(ies) full mailing address andtelephone number to include the ZIP Code. NOTAPPLICABLE to civilians.

ITEM 11d. Show the percentage to be paid to each person.Enter 10%, 20%, 30%, up to 100% as appropriate. The sumshares must equal 100 percent. If no percent is indicated andmore than one person is named, the money is paid in equalshares to the persons named. NOT APPLICABLE tocivilians.

ITEM 12a. Beneficiary(ies) for Unpaid Pay/Allowance(Military only). Enter first name(s), middle initial, lastname(s) and relationship of person to receive unpaid payand allowances at the time of death. The member mayindicate anyone to receive this payment. If the memberdesignated two or more beneficiaries, state the percentageto be paid each in item 10c. If the member does not wish todesignate a beneficiary, enter "By Law." The member isurged to designate a beneficiary for unpaid pay andallowances as payment will be made to the person in orderof precedence by law (10 USC 2271) in the absence of adesignation. Seek legal advice if naming a minor child asbeneficiary. NOT APPLICABLE to civilians.

ITEM 12b. Enter beneficiary(ies) full mailing address andtelephone number to include the ZIP Code. NOTAPPLICABLE to civilians.

ITEM 12c. If the member designated two or morebeneficiaries, state the percentage to be paid each in thissection. The sum shares must equal 100 percent. NOTAPPLICABLE to civilians.

ITEM 13a. Enter the name and relationship of the PersonAuthorized to Direct Disposition (PADD) of your remainsshould you become a casualty. Only the following personsmay be named as a PADD: surviving spouse, blood relativeof legal age, or adoptive relatives of the decedent. If neitherof these three can be found, a person standing in locoparentis may be named. NOT APPLICABLE to civilians.

ITEM 13b. Address and telephone number of PADD. NOTAPPLICABLE to civilians.

ITEM 14. Continuations/Remarks. Use this item for remarksor continuation of other items, if necessary. Prefix entry withthe number of the item being continued; for example, 5/JohnJ./son/ 19851220/321 Pecan Drive, Schertz TX 78151. Alsouse this item to list name, address, and relationship of otherpersons the member desires to be notified. Otherdependents may also be listed. This block offers thegreatest amount of flexibility for the member to record otherimportant information not otherwise requested butconsidered extremely useful in the casualty notification andassistance process. Besides continuing information fromother blocks on this form, the member may desire to includeadditional information such as: NOK language barriers,location or existence of a Will, additional private insuranceinformation, other family member contact numbers, etc. Ifadditional space is required, attach a supplemental sheet ofstandard bond paper with the information.

ITEM 15. Signature of Service Member/Civilian. Check andverify all entries and sign all copies in ink as follows: Firstname, middle initial, last name. Include rank, rate, or gradeif applicable. May be electronically signed (see DoDInstruction 1300.18 for guidelines).

ITEM 16. Signature of Witness. Have a witness(disinterested person) sign all copies in ink as follows: Firstname, middle initial, last name. Include rank, rate, or gradeas appropriate. A witness signature is not required forelectronic versions of the DD Form 93 (see DoD Instruction1300.18).

ITEM 17. Date the member or civilian signs the form. Thisitem is an ink entry and must be completed on all copies.

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MEMORANDUM FOR RECORD FROM: Northern Recruiting Squadron, Air Force Reserve Command Recruiting Service SUBJECT: Recruiter/Applicant Professional Relationship Contract Recruiter/Applicant Professional Relationship Contract As your Air Force Reserve recruiter, my goal is to provide you with the highest customer service possible while creating an atmosphere free of discrimination and sexual harassment. I will not unlawfully discriminate against, harass, intimidate or threaten you based on race, color, religion, national origin, or sex. Any conduct that creates an intimidating, hostile or offensive environment will not be tolerated. As an agent of the United States Air Force Reserve, I will not use my rank or position to threaten or pressure you. I will not promise you favorable treatment in return for personal favors. Furthermore, we will maintain a professional relationship throughout your recruiting process. I cannot and will not establish, or attempt to establish, or conduct an unprofessional, intimate, or sexual relationship with you. We expect all Airmen to promote the principles of equal opportunity at home and abroad. Living up to these principles is integral to our core values. We are personally committed to this endeavor and expect the same of you. ______________/_______________________ ___________ Recruiter (print and sign) Date Applicant - Recruiter Conduct and Professional Relationship Contract As an applicant for enlistment into the United States Air Force Reserve I have a responsibility to maintain a professional relationship throughout the recruiting process. It is my responsibility to treat this process as a job interview. I understand that I cannot engage or attempt to engage in any type of relationship outside of a professional relationship with my recruiter or any Air Force Reserve recruiting personnel. Failure to maintain a professional relationship may lead to disqualification from the United States Air Force Reserve. In addition, I understand I should never feel submission to an unprofessional relationship is required in order to gain employment with the Air Force Reserve. I understand I am obligated to report any inappropriate conduct by my recruiter or any Air Force Reserve personnel. The phone numbers to report inappropriate conduct are included on the Applicants Rights Card which has been provided to me. By signing below, I acknowledge that I understand the information in this form, watched the commander's video, and have received the applicant rights card from my recruiter. _____________________/________________________ __________ Applicant (print and sign) Date

DEPARTMENT OF THE AIR FORCE AIR FORCE RESERVE COMMAND

GL.2010.094 Ed. 04/2013 SGLV 8286

1. About You

3. About Your Beneficiaries Complete this section unless you are declining coverage

Print Name (First, Middle, Last) Rank, title or grade Social Security Number

Duty Location Branch of Service Current Amount of SGLI

I am completing this form to: (Check all that apply)

Name or update my SGLI beneficiary. You must complete sections 3 & 5.

Increase or restore my SGLI coverage to $

Reduce my SGLI coverage to $

Decline or cancel SGLI coverage. Write below “ I do not want insurance at this time.” You must complete section 5.

Coverage is available in

increments of $50,000 up to a maximum of $400,000

Servicemembers’ Group Life Insurance Election and Certificate

Have more beneficiaries? Check the box and complete Supplemental SGLI Beneficiary Form, SGLV 8286S.If you do not name beneficiaries above, your insurance will be paid by law (see page 3). * If the insured member elects a lump sum payment, the beneficiary(ies) will be given the option of receiving the lump sum payment through the Prudential

Alliance Account®, by check, or Electronic Funds Transfer (EFT). Alliance Account is not available for payments less than $5,000, payments to individuals residing outside the United States and its territories, and certain other payments. These will be paid by check.

Open Solutions Inc. is the Service Provider of the Prudential Alliance Account Settlement Option, a contractual obligation of The Prudential Insurance Company of America, located at 751 Broad Street, Newark, NJ 07102-3777. Draft clearing and processing support is provided by UMB Bank, N.A. Alliance Account balances are not insured by the Federal Deposit Insurance Corporation (FDIC). Open Solutions Inc. and UMB Bank, N.A. are not Prudential Financial companies.

Share to each (% or $ amounts)

Payment Option (Lump sum* or 36 equal monthly payments)

Primary Name and Address

Social Security Number (If available)

Relationship to you

1.

2.

3.

4.

Secondary

1.

2.

3.

4.

2. About Your Coverage

Page 1 of 4

Office of Servicemembers' Group Life Insurance

. You must complete sections 3, 4, & 5.

. You must complete sections 3 & 5.

“ .”

GL.2010.094 Ed. 04/2013 SGLV 8286 Page 2 of 4

I have read the instructions and understand that:

This form cancels any prior beneficiary or payment instructions.I can have SGLI and Veterans’ Group Life Insurance (VGLI) coverage at the same time, but the combined amount cannot be more than $400,000.

Reducing or declining SGLI coverage can affect the amount of my family coverage, traumatic injury coverage and post-separation coverage (see instructions for details).If I am married or get married after completing this form and have not declined SGLI, spouse SGLI automatically covers my spouse. If my spouse is also a member of the uniformed services and we were married on or after January 2, 2013, spouse SGLI coverage is not automatic, but I may apply for spouse coverage by completing SGLV 8286A. I must register my spouse in DEERS so my branch of service can deduct premiums from my pay. Failure to register my spouse in DEERS will result in my owing debts for unpaid premiums. I can decline spouse SGLI coverage by completing SGLV 8286A.

I am free to name anyone I want as my beneficiary. I certify that I understand if I have designated someone other than my spouse or child as my beneficiary, the person I have named is the person I intend to receive my insurance proceeds. I also understand that if I am married, my spouse may be notified that he/she (or my child) is not my designated beneficiary.

I certify that the information provided on this form is true and correct to the best of my knowledge and belief. Any deception or knowingly false statement either by inference or omission may result in cancellation of the insurance or in the refusal to pay a claim.

5. Your Signature You must complete this section.

Service Member Signature Social Security Number Date (MM, DD, YYYY)

For Branch of Service Use Only

Name of Personnel Clerk Representative

Rank, title or grade Approve

Contact telephone/email Disapprove

Date Date

Address

For OSGLI Use Only

Address

4. About Your Health Complete this section ONLY if you are restoring or increasing coverage.

Your date of birth (MM, DD, YYYY) Your weight Your height

Have you had, been treated for, or had known indications of: Yes Noa. A heart condition?

b. High blood pressure? c. A neurological disorder? d. Diabetes?

e. Cancer or tumors? f. Have you ever been diagnosed as having a disease of the immune system? g. Do you have any known physical impairments,

deformities, or ill health not covered above?

Your gender FemaleMale

Did you answer “YES” to any question? If so, reference the question by letter and list date, duration and details below.

Any request to increase coverage does not take effect until approved by the Office of Servicemembers’ Group Life Insurance (OSGLI).

Submit this form to your Unit Personnel Clerk.

GL.2010.094 Ed. 04/2013 SGLV 8286

Information for the Service MemberAbout your SGLI CoverageServicemembers’ Group Life Insurance (SGLI) is granted under title 38, United States Code, and is subject to the provisions of that title and its amendments, and title 38 Code of Federal Regulations.

The following charts provide information you should review before naming a beneficiary or selecting a payment option.

Naming Beneficiaries who will receive the insurance

If you… Then…are married and decline coverage upon entry into service

your spouse will be notified that you declined coverage.

are married and designate any person other than your spouse or child for any amount of insurance

your spouse will be notified in writing that he/she or your child is not the named beneficiary, unless:– your spouse has been previously notified, OR – your spouse is not designated as beneficiary for any amount of insurance prior to the new election.

are married and your spouse is designated as beneficiary and you decline coverage or elect less than maximum coverage, and that election reduces your coverage from the automatic maximum or from a previously elected amount of coverage

your spouse will be notified in writing of your election to decline or reduce coverage.

have any life event such as marriage, divorce, or children after completing this form

you should complete a new beneficiary form. Beneficiaries are not automatically changed by life events.

name more than one beneficiary the sum of the shares must equal 100% or the full dollar amount of your insurance.

want to name more than four primary or secondary beneficiaries

you must complete the SGLI Supplemental Beneficiary Form, SGLV 8286S.

name minors as beneficiaries SGLI will pay the insurance benefit to the court-appointed guardian of the children’s estate if the beneficiary is a minor at time of claim.

you can establish a trust for the benefit of the children and name the trust as beneficiary. A trust names a trustee of your choice to be legally responsible for administering the insurance proceeds for the children.

naming a trust as a beneficiary on this form does NOT create a trust.

name more than one primary beneficiary and one or more of them predeceases you

SGLI will pay the shares equally among the remaining primary beneficiaries.

want to name a Trust as a beneficiary you must create a trust. Please consult with a military attorney, professional financial planner, or estate planner to help you create Trust documents. (Please note: Trust documents are not needed until a claim is submitted.)

have no surviving primary beneficiaries SGLI will divide the insurance benefit among the secondary beneficiaries.

do not name a beneficiary or there are no surviving primary or secondary beneficiaries OR indicate that payment should be made by law

SGLI will pay the insurance benefit in the following order:1. Widow or widower2. Children in equal shares (the share of any deceased child will be distributed equally among the

descendants of that child)3. Parent(s) in equal shares or all to surviving parent4. A duly appointed executor or administrator of your estate5. Other next of kin

Payment Options

If you want the beneficiary to… Then…

receive the insurance proceeds in one lump sum

write the phrase “lump sum” under Payment Options. If you elect a lump sum payment, your beneficiary(ies) will be given the option of receiving the lump sum payment through the Prudential Alliance Account®*, by check, or Electronic Funds Transfer (EFT).

* Alliance Account is not available for payments less than $5,000, payments to individuals residing outside the United States and its territories, and certain other payments. These will be paid by check.

receive the insurance proceeds in 36 equal monthly payments

write “36” under the Payment Option.

your beneficiary cannot change this payment option.

have a choice write the phrase “lump sum” under Payment Option or leave blank.

Page 3 of 4

GL.2010.094 Ed. 04/2013 SGLV 8286

Instructions for Personnel Clerk and the Service Member1. A representative of the Uniformed Services must complete the “For Branch of Service Official Use Only” section to indicate receipt of the

form from the member after reviewing the following table:

If the service member…The Personnel Clerk should inform the service member… Then the Personnel Clerk should…

has just entered the service he or she is automatically insured for $400,000 SGLI, unless the service member declines or reduces coverage.

have the service member designate beneficiaries by completing SGLV 8286.

is increasing or restoring SGLI he or she must complete Section 4, About Your Health. approve form if the responses to questions 4a through 4g are “No” and forward the form to payroll to change SGLI premium deductions.send form to OSGLI if any answer to questions 4a through 4g are “Yes.” Only inform payroll when approved by OSGLI.

Reduces, declines, or cancels SGLI

an application with health questions is required to increase, elect, or restore coverage at a later date.

of the following: – the purpose and role of life insurance in financial planning.– the difference between term life insurance and whole life insurance.– the availability of commercial life insurance.– the relationship between SGLI and VGLI.– declining or canceling SGLI will also cancel Family SGLI— both

spouse and dependent child coverage— and Traumatic Injury Protection (TSGLI).

forward the form to payroll to change SGLI premium deductions.

if canceling SGLI, have the service member complete SGLV 8286A to end payment of Family SGLI premiums. No form is required to end TSGLI premium deductions.if the member is married and reduces, declines, or cancels SGLI, inform the member that his her spouse may be notified in writing of the member’s election based on Title 38, USC 1967 (f).

is married or gets married after completing this form (and is not married to another member of the uniformed services)

gets married to another member of the uniformed services on or after January 2, 2013

spouse SGLI automatically covers spouse.he or she must register their spouse in DEERS for payroll to deduct premiums.

If the member wants to decline coverage or take a lesser amount of spouse coverage, the member must complete SGLV 8286A.

if applicable, forward the form to payroll to begin premium deductions for the spouse coverage.

if member wants spouse SGLI coverage, provide the member with SGLV 8286A, Spouse Coverage Election and Certificate, and follow the instructions therein.

spouse SGLI coverage is not automatic and the member may apply for spouse SGLI coverage by completing SGLV 8286A.

has questions about this form the advice of a military attorney is available at no expense. direct them to the appropriate resource.

wants to designate more beneficiaries than the form allows

he or she must complete the Supplemental SGLI Beneficiary Form SGLV 8286S.

attach the Supplemental Beneficiary Form to the 8286.

designates any person other than his/ her spouse or child for any amount of insurance

while the member is free to designate anyone he or she chooses as beneficiary, the member must certify that he or she is designating someone other than a spouse or child and the person named will receive the benefit.

if the member is married, the member’s spouse will be notified in writing that he/she or the member’s child is not the named beneficiary, unless:– the spouse has been previously notified, OR– the spouse is not designated as beneficiary for any

amount of insurance prior to the new election.

have the member sign SGLV 8286 to certify that he/she understands that:

he/she is free to name anyone as beneficiary.

if he/she designated someone other than his/her spouse or child as beneficiary, the person the member has named is the person he/she intends to receive the insurance proceeds.

if married, the spouse will be notified that he/she (or any child) is not the designated beneficiary.

Page 4 of 427305-1012

2. After the form is completed, Personnel Clerk should:

File a copy in the member’s official personnel file

Provide a copy to the service member

Provide a copy of the form to the payroll office for the member’s unit

Submit the form to OSGLI ONLY if the member is increasing or restoring SGLI coverage and answered “Yes” to one or more of the health questions

OSGLI PO Box 41618 Philadelphia, PA 19176-9913

STATEMENT OF RESERVE SERVICE COMMITMENT

If selected for officer training school or undergraduate flight training, I accept the appropriate Reserve Service Commitment as specified in AFRCI 36‐2102, Air Force Reserve Service Commitment Date Program, dated March 2004. This statement must be signed and dated by the applicant and witnessed by a recruiting or military personnel official.

Name of Applicant (type or print) Signature of Applicant

Applicant’s Social Security Number Date

Name of Witness (type or print) Signature of Witness

UNSPONSORED CANDIDATES ONLY

I understand that if selected, my name and summary information will be transmitted to AFRC flying units.

Interested units will contact me or my Officer Accessions recruiter and the preferred method of

assignment will be an offer of employment from an interested unit. However, if I am not offered

employment by any AFRC units, I will receive an assignment in accordance with the needs of the AF

Reserve near the end of my UFT training. I understand that I must serve at least three years in the unit I

am assigned before pursuing employment at any other unit. Additionally, I understand that I may be

granted as little as 6 months of full time orders upon completion of formal aircrew training.

Name of Applicant (type or print) Signature of Applicant

Applicant’s Social Security Number Date

Name of Witness (type or print) Signature of Witness

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RANDALL A. OGDEN, Maj Gen, USAF28 Sep 17 OGDEN.RANDALL.A.1162727288Digitally signed by OGDEN.RANDALL.A.1162727288Date: 2017.09.28 15:11:28 -07'00'

*** Block 20 is for the Wing Commander to sign, Block 21 is for NAF CC if an ETP is required

Applicant's PAS CODE:

BORN ABROAD OF US PARENTS

MARRIED TO MILITARY MEMBER

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 TO YOUR RECRUITER OR BASE EDUCATION SERVICE CENTER.

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

4. LEGAL STATE OF RESIDENCE (Include Zip Code)

1. NAME (Last, First, Middle Initial) (Maiden, if applicable)

GRADE TAFMSD CURRENT DOS

SERVICING MPF (Complete mailing address)

BASE EDUCATION SERVICE OFFICE

HOME E-MAIL ADDRESS:

(BESO)

COML:

DSN: DSN FAX:

COML FAX:

CURRENT UNIT OF ASSIGNMENT (Complete Mailing Address)

CAFSC:

COML: DSN:

2. CURRENT ADDRESS Include Area Code)

(Complete Mailing Address and Phone Number to

3. HOME ADDRESS (Home of Record)

SSN DATE OF BIRTH

NUMBER OF DEPENDENTS (Other than spouse, completely dependent on you)

APPLICANT'S WORK E-MAIL ADDRESS:

OTHER (Specify)

FORM VERSION DATE TESTED PILOT NAV AA VERBAL # OF TIMES TESTED

DATE DEPARTED

DATE ELIGIBLE TO RETURN FROM

DATE AVAILABLE FOR TRAINING

QUANTITATIVE

BESO COUNSELOR'SE-MAIL ADDRESS:

OTHER

6. ACTIVE DUTY MILITARY APPLICANTS ONLY

IN THE UNITED STATES AIR FORCEAPPLICATION & EVALUATION FOR TRAINING LEADING TO A COMMISSION

Expires 31 Mar 2009OMB NO. 0701-0150

PRIVACY ACT STATEMENTAUTHORITY: 10 U.S.C., Armed Forces, 2107, Financial Assistance Program for Specially Selected Members; 10 U.S.C. 9411. Establishment and Purpose of Schools and Camps; EO 9397.PRINCIPAL PURPOSE: To document evidence of application for consideration to enter an officer training program leading to a commission and voluntary contractual agreement to serve the period specified.ROUTINE USES: None.DISCLOSURE IS VOLUNTARY: Failure to furnish the information may result in denial of consideration for training leading to a commission.

Headquarters Services, Directorate for Information Operations and Reports (0701-0001) , 1215 Jefferson Davis Highway, Suite 1204, Arlington VA 22202-4302.

(C) Enter all dates using year, month and day sequence (i.e., 19950715).

prior to signing this application.(D) Be certain that you understand and agree to the certification in item 23

(E) Enter "NA" or "Not Applicable" for any item that does not apply or to whichyou have no response.

(F) Include an official transcript, including transcript key, for each earneddegree reflected in Item 24.

NOTE: Your home of record is the place designated as your home when you arecommissioned, reinstated, appointed, reappointed, enlisted, inducted, or ordered to active duty. This address is used to determine travel entitlements when you separate from active duty.

BESOTELEPHONES:

DUTY TELEPHONES:

5. PERSONAL DATA

7A. APPLYING FOR: (Check & initial program & category for which you apply)

OFFICER TRAINING SCHOOL (OTS)

AFROTC

AIRMAN EDUCATION AND COMMISSIONING PROGRAM (AECP)

(Specify)

7B. RATED LINE CATEGORIES (OTS Applicants Only) (List 1st and 2nd Choice)

PILOT NAVIGATOR AIR BATTLE MANAGER

7C. NON-RATED LINE AF SPECIALTY CHOICES

PRE-HEALTH NURSE8. NON-LINE:

For AFROTC/AECP, indicate 1 desired degree title.)

(1)

(2)

(3)

9. AFOQT SCORES (Most Recent) (Include score printout with application.)

AF Form 56, 20061030

SECTION I

INSTRUCTIONS

NO

7D. VOLUNTEER FOR FLYING DUTY

YES

PAGE 1 OF 7 PAGESPREVIOUS EDITIONS ARE OBSOLETEFOR OFFICIAL USE ONLY (When filled in)

(A) All entries must be typed, except where otherwise indicated. Add the ZIP Code to all addresses.

NATURALIZED

NATIVE BORN

(If Yes, check appropriate item)

MARRIED TO CIVILIAN

SEPARATED DIVORCED

WIDOWED

MARITAL STATUS:

SINGLE

U.S. CITIZEN:

YES NO

(B) When allotted space is insufficient, continue on page 7 when needed.Provide a complete explanation for each item (Identify each item withthe item number.)

(For AFRS, indicate 3, using utilization field titles not codes.

121-12-1212

1 2

GA 31098

MAKE SURE YOU MARK BLOCK 7D

11

Accessions, Officer NMI,

12 Main StWarner Robins, GA 31098321-222-5555

x

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

AFI36-2005 2 AUGUST 2017

APPLICANT BRIEFING ITEM ON SEPARATION POLICY

A8.1. Brief applicants, prior to the commissioning oath, as follows:

A8.1.1. As military members, you occupy a unique position in society. You represent the

military establishment. This special status brings with it the responsibility to uphold and

maintain the dignity and high standards of the US Armed Forces at all times and in all places.

The Armed Forces must also be ready at all times for worldwide deployment. This fact

carries with it the requirement for military units and their members to possess high standards

of morale, good order and discipline, and cohesion. As a result, military laws, rules, customs

and traditions include restrictions on your personal behavior that may be different from

civilian life. Members of the Armed Forces may be involuntarily separated before their term

of service ends for various reasons established by law and military regulations. Some

unacceptable conduct may be grounds for involuntary separation, such as:

A8.1.1.1. You establish a pattern of disciplinary infractions, discreditable involvement

with civil or military authorities or you cause dissent, or disrupt or degrade the mission of

your unit. This may also include conduct of any nature that would bring discredit on the

Armed Forces in the view of the civilian community.

A8.1.1.2. Because of parental responsibilities, you are unable to perform your duties

satisfactorily or you are unavailable for worldwide assignment or deployment.

A8.1.1.3. You fail to meet the fitness standards.

*RESTRICTIONS ON PERSONAL CONDUCT IN THE ARMED FORCES

Military life is fundamentally different from civilian life. The military has its own laws, rules,

customs, and traditions, including numerous restrictions on personal behavior that may be

acceptable in civilian society. These are necessary because military units and personnel maintain

the high standards of morale, good order and discipline, and unit cohesion essential for combat

effectiveness.

The Armed Forces must be ready at all times for worldwide deployment. Military laws and

regulations, including the Uniform Code of Military Justice, apply to service members at all

times, both on base and off base, from the time the member enters the service until the member is

discharged or otherwise separated from the Armed Forces.

*Members of the Armed Forces may be involuntarily separated before their term of service ends

for various reasons established by law and military regulations, such as: (a) member may be

separated for a pattern of disciplinary infractions, a pattern of misconduct, commission of a

serious offense, or civilian conviction, (b) a member who has been referred to a rehabilitation

program for personal drug and alcohol abuse may be separated for failure through inability or

refusal to participate in, cooperate in, or successfully complete such a program, (c) a member

may be discharged by reason of parenthood, if it is determined the member because of parental

responsibilities, is unable to perform his or her duties satisfactorily or is unavailable for

worldwide assignment or deployment, or (d) a member may be separated for failure to meet

service fitness standards.

Applicant Name _____________________

Signature __________________________

I acknowledge and will adhere to the Applicant Briefing Item on Separation Policy.

I. IDENTIFICATION DATA (Read AF! 36-2406 carefully before filling in any item)

12.SSN

13. GRADE

14. DUTY AFSC

2Lt 92RO

1. NAME (Last. First. Middle Initial)

5. ORGANIZATION. COMMAND. AND LOCATION

Chaplain Candidate Program (RMG/Det I 3A) AFRC/1 ICX, Robbins AfB GA 31098-1637

6. PERIOD 01= REPORT I THRU:

7. LENGTH OF COURSE 8. REASON FOR REPORT

FROM: 27 May 2014 30 Jun 2014 5 WEEK(S) r-1 ANNUAL r-J FINAL 121 DIRECTED

9. NAME AND LOCATION OF SCHOOL OR INSTITUTION 633 ABW/IIC180 Dodd Blvd, Bldg 59 I, Langley AFB, VA 2366510. NAME OR TITLE OF COURSE Chaplain Candidate Follow-On TourII. REPORT DATA (Complete as applicable for final report)

1. AFSCIAERO RATING/DEGREE AWARDED

l2

0 COURSE NOT COMPLETED (List reason in Item 4 below)

3. DISTINGUISHED GRADUATE [l YES (List criteria in Item 4 below) D NO DG PROGRAM 4. DG AWARD CRITERIA/COURSE NONCOMPLETION REASON

Ill. COMMENTS (Manda/ON) ACADEMIC/TRAINING ACCOMPLISHMENTS - Ldrshp plus! 1st to vol f/ toughest jobs; knows how to recruit/build teams/lead people fl max impact & results!- Stellar chap candidate; invaluable resource in busiest part of yr w/reduc'd manning--as productive as AD chap- Provid'd ldrshp r/ Traditional Protestant Svs to include bulletin design, ldrship of vols and dynamic preaching- Energiz'd/assist'd in jump-starting a multifaceted HC driven outreach pgnn--propcll'd min to AD Arnn/families- Showed clear comprehension and desire to learn in .all areas of supervision in the CCSJP--exceeded all goals- Lean'd forward w/ ancillary trng: IA, Anti-Terrorism, Self-aid Buddy Care, SART and other HC specific trng- Infused energetic vitality into Single Airmen Mnstry--impact at all dorm events encouraged >820 in attendance- Base-wide impact: orchestrat'd/oversaw Jordan Hall dorm move, mobiliz'd 50+ vols/fill'd 7 trucks--msn done- Off-the-chart visibility; accrued I 05 flightlinc, FD, MDG, SFS, & CE hrs--a ministry of presence to 750+ AD- Full court press at the MED GRP! Visitaion of 80 amn/mentoring voluntcers/organiz'd pizza feed for AD prsnl- Master'd Comprehensive Airman Fitness material; brief d IrC staff on Spiritual Component--excellent speaker- Spiritual energizer--investcd 60 hrs spiritually nurturing airmen in the workplace--Amn relaxed and refocused- Force multiplier; pwrful presence fl reintegration/pre-deployment briefs--200 warfighters prep'd fl duty/home- Spearhead'd "Beat the Heat I & II, provid'd popsicles/cold water to Arnn in 100+ temp--315 I FW amn cheer'd- Better than peers! Outstanding confidcneefjob proficiency; unquestionably best AF's chap candidate I've seen

PROFESSIONAL QUALITIES (Bearing. appearance, conduct, fitness)

- Impeccable prfsnl image, sharp mil bearing, yet approachable as any AD chap--he looks, acts, & lives the part- Instant implementation of supervisor suggestions/tasks/scheduling, thus extremely teachable--highly productive- Well-organized/timely in all academic requirements; show'd solid aptitude fl admin; kept supervisor informed- Deals well w/ pluralistic military environment; sensitive to needs/culture of all; seeks for mnstry opportunities- Highly creative talents & approach to ministry; invaluable resource to any HC team fortunate enough to get him- Amazing chap candidate/ofcr competent on day I; not intimidat'd, confident, humble, a HC team player/builder- Core values incarnate--demonstrat'd striking work ethic by coming early/staying late w/out direct supervision- Display'd keen self/social awareness beyond his years in life & mnstry experience; vector f/ AD then CPE slotOTHER COMMENTS (Optional)

- What a great candidate! It is hard to believe Brent is .a 1st year/I st tour candidtate--l'd take him AD right now- This Chap Candidate is tenacious; whether he srvs at a burger burn or wins a push up contest against "firedogs"- All JBLE Chaps agree; Lt Little has proven to be a superior candidate, worthy of full & complete endorsement- Alwys uplifting, alwys helpful, alwys keeps his head, alwys brings a positive focus to every issue or situation- Superb young ofcr/pastor! I 00% in the game 24/7, never needs polishing, he shines--bring on AD at graduationIV. EVALUATOR

NAME. GRADE. BR OF SVC. ORGN. COMO, LOCATION

Steven E. West, Ch, Col USAF 633 AHW/HC Langley AFB, VA 23665

AF IMT 475, 20000601, V1

DUTY TITLE

Wing Chaplain SSN

-

PREVIOUS EDITION IS OBSOLETE

FOR OFFICIAL USE ONLY (when filled in)

I DATE

SIGNATURE

EDUCATION/TRAINING REPORT

I I !

I. IDENTIFICATION DAT A /Read AF/ 36-2406 carefully before filling in any item)

-1-.-NAME (Last. First. Middle Initial)

2U 92RO -- - - -- ---

12. SSN 13 GRADE

- --·

- -- -- --- --

_j 4. DUTY AFSC

-- ----·--·-5. ORGANIZATION. COMMAND, AND LOCATION

Chaplain Candidate Program (RMG/Det l3A), AFRC/HCX, Robins AFB, GA 31098 C---

6 PERIOD OF REPORT ; J. 7 LENGTH OF COURSE rREASON FOR REPORT

FR�� 13 Jul 2013 J THRu _14 Aug 2013 _ 5 WEEK(Sl � i_

ANNUAL LI FINAL b(I DIRECTED ___

9. NAME AND LOCATION OF SCHOOL OR INSTITUTION

Robins AFB, GA; Joint Naval Reserve Base Fort \Vorth. TX; Lackland AFB, TX: Barksdale AFB, LA: Joint Base Charleston, SC - --- -- -- - -·· - -- -----�--- --------'10. NAME OR TITLE OF COURSE

II. REPORT DATA (Complete as applicable for final repolt) I 1 AFSC/AERO RATING/DEGREE AWARDED

I\ 1 COURSE NOT COMPLETED (List reason in Item 4 below) .. ..

!:/I 3. DISTINGUISHED GRADUATE YES /List criteria in Item 4 below) NO DG PROGRAM >-·· -

4. DG AWARD CRITERIA!C:)URSE NONCOMPLETION REASON

J!!,.COMMENTS (Mandato!Xl...._ ACADEMIC/TRAINING AC ,OMPUSHMENTS - Solid performer on this challenging 34-day training tour via mil air to five bases/MAJCOMs--AD/Guard/Res- l 4 hrs of high-stress expeditionary ministry field training: Land Nav/COIN/cultural engagement/field exercises- Recd' 4 l hrs ins1ruction on pastoral care. advising leaders. rel accommodation, RST concept & visitation min- Participated in 20 group mentoring sessions discussing clergy/officer balance, chaplain mission/spiritual care- Exposed to cutting-edge warrior care & CPE prgm; engaged w/Chaplains & patients at SAA MC & VA hosp- Attended/reflected on five diverse worship services incl Prot (BMT/Contemp/Liturgical), Catholic & Muslim!- Exposed to Joint Ops environment: JSTARS, Army/HC, Navy MAG/HC. Navy/HC & AF--total force savvy- Superb ministry of presence! Effectively engaged w/40+ airmen & family members in seven hrs of visitation- Great facilitator! Skillfully led 2 I-hr flt' meetings, keeping team on task & on schcdule--organized & confident- Flawlessly served as color guard/flag-folder at Alamo memorial--best flt-led ceremony I've seen/4 yrs of CCII- Provided 4 authentic & passionate night prayers & I squadron (pluralistic) prayer--always sincere & caring!- Shared 2 thought(ul flt devotional messages: speaks from the heart w/spiritual passion & sinccrity--grea.t effort! - Creatively delivered message for I 5 children at Robins AFB chapel--fun, flexible & adept at teaching all ages- Sets the pace! Leader of flt PT program. ensuring l 00% accountability to assigned fitness tasking of 3x/week- bxcdlent ,\Titing skills! Crafted best PT accountability report form I've seen in 4 tours; articulate work recordPROFESSIONAL QUALITIES /Bearing, appearance. conduct. fitness)

- Outstanding military bearing! Flawless customs & courtesies--always conducted himself w/professionalisrn- Solid officership; punctual. responsible & respects the chain of command--a tireless leader/steadfast follower- A kind. caring soul--his youthfoL energetic enthusiasm always bolstered his flt & was key to their success- Always wore the uniform w/pride and professionalism; wonderful example of integrity, service & excellence!- A team-player thr0ughout this challenging tour: respectful & humble attitude--always an encouraging presence- Committed to his theology & faith tradition yet able to work in a pluralisti'c cnvironmcnt--ready to support all!- Standup performer as Ass't Flt Leader: kepl element mission-focused & l 00% accountable on final leg of tour- 1v1aoe fitness a pnont.y 6y worKmg ou· Jx/wecl<--team awanted "r1tness Teamwork Award" for top fitness flt!

--OTHER COMMENTS /Opt1<>na!J

- Very strong candidate w/soaring potential! Superb attitude & always tcachable--continue to invest in this one!- Key-player in a very strong flt: winner of "Outstanding Flight" award--his gracious & positive attitude \Vas key- Proven character & military bearing; continue to give him more opportunities to demonstrate his ministry skills- Recommend follow-on tour at chapel looking for an energetic, highly-fit Candidate eager to grow & develop- Reappoint this strong Candidate as Res Chaplain upon completion of educational/ecclesiastical requirements!

�'::!;'.��?� OF SVC ORGN, COMO, LOCATION DUTY TITLE

IDATE

Pierre M. Allegre. Ch, Maj. USAFR Wing Chaplain I 14 Aug 2013 446 Airlift Wing SSN

'SIGN

��

Joint Base Lewis-l\lcChord. \VA 9707

AF IMT 475, 20000601, V1 ?REVIOUS EDITION IS OBSOLETE EDUCATION/TRAINING REPORT

FOR OFFICIAL USE ONLY (when filled m}

.

RIC Certification

APPLICANT NAME:

I certify member meets all eligibility requirements for entry into the Air Force Reserve.

Appropriate body fat measurement documentation uploaded in AFRISS-TF:

Verify specialty qualified for JAG and Chaplain Programs:Bonus Agreement uploaded into AFRISS-TF:

Recruiter Name:

QC/Review SF86 or Proof of Clearance: Finger print cards reviewed: Credit Report (Age 25+ or morals waiver):PS / NPS Source Docs Uploaded?

DD Form 93 and SGLI Form 8286 are accomplished (Except Assignments):Applicant /Recruiter Reationship Statement?

Review AFRISS Remarks:

Verify PS > 84 Days, completed IADT / PS Branch / AND / Training Code / Enlist, Assign or Appoint TypeGain and/or EDSCA date correct:

Verify Bonus Eligibility:Verify Accession Category:

Miscellaneous:

Additional requirements annotated in accordance with AFOCD:Unit / PAS Code / Authorized Grade / Position # match blocking document:Assigned Grade matches source document? DOR Correct?Verify TAFMSD / Pay Date / TYSD:Verify Enlistment/Assignment/Appointment Type:

Dates of Service: RE / SPD Code / Character of Service:AFSC or MOS / Job Title:

Most Current Conditional Release Annotated : Approved? Expired?Gain Tab

DAFSC / Primary AFSC Correct: Correct Shred?

Verfiy Grade Revelance and/or ISLRS drop down menu are correct for all Officer periods of service:

Verify DD 2808 Page 2 has drugs stamp with all "N's": HIV 5B (Neg)AFOQT - Flying: P25, N10 and P+N = 50: AFOQT - Non - Flying: V15, Q10, A15, and V+Q+A = 100: Review DD 2808 Items 37 /44 / 73: Review 2807-1 Page 3 & 4:Tattoos reviewed: Annotated in AFRISS or RSOO approval uploaded?

Prior Service Tab

Education/Test TabPlace of birth matches source document:Graduation Date / Education Level matches source document:

CAP / Scouts / JROTC:

Test & PhysicalVerify JAG Credentials: Verify Chaplains have MDIV with 72+ hours or Chaplain Candidates enrolled in Seminary:

Verfiy Degree program is qualifying for AFSC IAW AFOCD:

Verify citizenship: Verify C C M A P P E D D S :Verify height/weight: Verify DL# & Expiration:

Morals TabCharge matches court documents/Physical: Disposition:Review comments on DD 2807-1 Page 3 & 4

Officer Accessions QC Validation PROJECTED GAIN DATE:

Demographics Tab

SSN matches source document:DOB / Name match source document:

Verify proper processing program:Verify Grade Calculation and Scroll approval:

PROCESSING PROGRAM:

Verify proper physical for specific program:Verify commission physical certified by MEPS or AFRC/SG:

Verify Fit to Fight on Assignments when PHA shows over MAW:Verify FC1 Physicals are certified and completed MFS:

Ensure Attachment 5 applicant statement is attached for any "YES" responses on AF Form 2030:

Verify Height, Weight & BFM / Hair & Eye Color:CV (12/14 +) & DP (Only D, E, or F Pass):Verify "H" Factor (H-2 is anything over 25,25,25,35,45,45): AFI 48-123 ATCH 3AF 2030 & DD 2807-1 Page 3 match:

AFRC/RS OA QC V1, 20141008

OA PROGRAM CHECKLIST ATTACHED :

USAF JUDGE ADVOCATE GENERAL APPOINTMENT KIT CHECKLISTS

EACH APPLICANT SHOULD KEEP A COPY OF ALL COMPLETED FORMS IN A PERSONAL FILE OF CORRESPONDENCE AND FORMS TO ESTABLISH A CAREER RECORD. PLEASE DO NOT STAPLE ANY FORMS TOGETHER.PLEASE USE ONLY ONE.

A: AIR FORCE JUDGE ADVOCATE GENERAL APPOINTMENT KIT CHECKLIST B: AIR FORCE JUDGE ADVOCATE GENERAL ASSIGNMENT KIT CHECKLIST

A: JUDGE ADVOCATE GENERAL APPOINTMENT KIT CHECKLIST (ONLY)PLEASE USE THE ATTACHED INSTRUCTIONS.

ONE PAGE PERSONAL STATEMENT OF WHY YOU SEEK TO JOIN THE AIR FORCE JA PORGRAM.(IMA APPLICATION, INCLUDE A LIST OF 3 PREFERRED BASES FOR ATTACHEMENT)AF IMT 883, PRIVACY ACT STATEMENT – US AIR FORCE APPLICATION RECORDMILITARY BIO OR CIVILIAN RESUMEAF IMT 1288, APPLICATION FOR READY RESERVE ASSIGNMENTAF IMT 24, APPLICATION FOR APPOINTMENTAF IMT 2030, USAF DRUG AND ALCOHOL ABUSE CERTIFICATEVERIFICATION OF EPSQ AND OPM FORMS SUBMISSION (RECRUITER PROVIDES FD FORM 258 FINGERPRINT CARD.

PHYSICAL EXAM RECORD, SHOWING APPLICANT IS MEDICALLY QUALIFIED

TRANSCRIPT OF COLLEGE CREDITS WITH IMPRESSED SEAL AND OFFICIAL SIGNATURE, SENT DIRECTLY FROM REGISTRAR TO RECRUITER. MUST SHOW DEGREE GRANTED.RECOMMENDATION LETTER FROM AN ACTIVE DUTY STAFF JUDGE ADVOCATE

CERTIFICATE OF GOOD STANDING FROM THE HIGHEST COURT BEFORE WHICH YOU ARE ADMITTED TO PRACTICE

VERIFY APPLICANT GRADUATED FROM AN ABA ACCREDITED LAW SCHOOL

VERIFY MEMBER IS IN GOOD STANDING OF THE BAR OF A US STATE, PUERTO RICO OR A US TERRITORY

WAIVER REQUESTS AS NEEDED

AF IMT 3010, USAF STATEMENT OF UNDERSTANDING OF DEPENDENT CARE RESPONSIBILITY (IF SINGLE PARENT)

AF IMT 357, FAMILY CARE CERTIFICATION (IF MARRIED TO A MILITARY MEMBER)

PRIOR MILITARY SERVICECOPY OF DISCHARGE CERTIFICATE, COPY OF DD FORM 214, CERTIFICATE OF RELEASE OR DISCHARGE FROMACTIVE DUTY, AND/OR STATEMENT OF SERVICE (All prior service documents that are applicable).DD FORM 368, REQUEST FOR CONDITIONAL RELEASE, IF IN CURRENT ACTIVE STATUS OR INTER-SERVICE TRANSFER (ACTIVE, GUARD, OR RESERVE STATUS), FROM YOUR UNIT (INITIATE WITH YOUR UNIT).ALL OFFICER PERFORMANCE REPORTS FOR PRIOR MILITARY OFFICERS

B: JUDGE ADVOCATE GENERAL ASSIGNMENT CHECKLISTGRADUATE OF AN ABA ACCREDITED LAW SCHOOL

MEMBER IN GOOD STANDING OF THE BAR OF A US STATE, PUERTO RICO OR A US TERRITORY

AF IMT 1288, APPLICATION FOR READY RESERVE ASSIGNMENTCURRENT RCPHA VERIFICATION BY E-MAIL OR LETTER FROM ARPC/SGP SHOWING MEMBER IS MEDICALLY QUALIFIED; OTHERWISE, PHYSICAL EXAM RECORDVERIFICATION MEMBER ATTENDED THE 9 WEEK AIR FORCE JUDGE ADVOCATE STAFF OFFICER COURSE IN RESIDENCE AT MAXWELL AFB, AL, OR EQUIVALENT (IN RESIDENCE) COURSE OF ANOTHER ARMED SERVICE

Applicants accepted into the Judge Advocate General’s Corps, will be required to attend a total of 13 weeks of initial training in-residence at Maxwell Air Force Base, AL unless they have already been designated a Judge Advocate and attended this training.

USAF JUDGE ADVOCATE GENERAL APPOINTMENT KIT CHECKLISTSECK

of 3

USAF RESERVE CHAPLAIN CORPS CHECKLIST

Applicant Name:_________________________________ Officer Accessions Recruiter’s Name:___________________________

TO THE APPLICANT: Use the appropriate column on the left for your type of application. Contact one of the Chaplain Recruiters listed below ifyou have questions regarding the appropriate column to use.

Chaplain Recruiter Contact InformationCh, Lt Col Amy Hunt255 Richard Ray Blvd, Ste 111, Robins AFB, GA 31098-1637Office: 478-327-2274 e-mail: [email protected]

Ch, Maj Philip Spitzer550 D Street West Suite 1, JBSA-Randolph, TX 78150-4527Office: 210-565-0335 Email: [email protected]

Chaplain CandidateReappoint

NA

Direct Appoint

*(1) PERSONAL ESSAY

*(2) RESUME

NA NA (3) CHAPLAIN CANDIDATE TRAINING RECORD

NA NA (4) SEMINARY DEGREE PLAN

*(5) DD FORM 2088, STATEMENT OF ECCLESIASTICAL ENDORSEMENT

NA NA (6) ENROLLMENT VERIFICATION

(7) SIGNATURE DOCUMENTS

NA (8) AF FORM 24, APPLICATION FOR APPOINTMENT

(9) AF IMT 1288, APPLICATION FOR READY RESERVE ASSIGNMENT

*(10) TRANSCRIPTS

(11) WAIVERS

NA NA (12) INTERVIEW (DOCUMENTS MARKED “*” NEEDED FOR INTERVIEW)

NA (13) AF FORM 2030, USAF DRUG AND ALCOHOL ABUSE CERTIFICATE

(14) SEPARATION POLICY

(15) VERIFICATION OF E-QIP VALIDATION

(16) PRIOR/CURRENT SERVICE DOCUMENTS (SEE 16A-E BELOW)

PRIOR AND CURRENT MILITARY SERVICE (16a) DD FORM 214, FORM 22, And/or ALL PRIOR SERVICE DOCUMENTS

NA (16b) DD 368 & PDF

NA NA (16c) AF FORM 475 – CHAPLAIN TRAINING RECORD

(16d) OPR/EPR Last Updated: 5 December 2017

* Items needed prior to HCX scheduling the interview.

USAF RESERVE CHAPLAIN CORPS CHECKLIST

Applicant Name:_________________________________ Officer Accessions Recruiter’s Name:___________________________

UUSAF Reserve Chaplain Corps Checklist Item Descriptions

Page 2 of 3Last updated 5 December 17

Y(This item is required for both Candidates and Direct Appoints starting FY18) Respond to the following in essayform in no more than two pages. Set up as you would an assignment from your seminary—double-spaced,appropriate margins, etc. Sign your name at the end of the essay and return as a PDF. Your essay should:1. Briefly explain the path – spiritual and personal – that led you to apply to the Chaplain Program.2. With so many opportunities to serve as a clergyperson, why is the Air Force Chaplaincy your choice?3. What are your goals for participation in the Chaplain Program?4. Do you see yourself serving on Active Duty, in the Reserve, or in the Air National Guard? Why?5. From your current perspective, what is the role of a chaplain in the USAF?6. In what aspects of your life journey will the Chaplain Program challenge you to improve?

( )Your resume must include 3 letters of recommendation w/contact information. Letters should be from a faithgroup leader, employer/supervisor and friend dated no later than 6 months ago.

(3) CHAPLAIN CANDIDATE TRAINING RECORDComplete both pages (candidate and chaplain recruiter work together on this).

( )Must be for an MDIV (or equivalent) / 72 hr minimum / accredited program. Scan a PDF of the degree plan. Do

not send a link to an online catalog. The degree plan should state name of degree, classes required and totalcredit hours.

(5) DDThis must come directly from your endorser to your Chaplain Recruiter. Inform your endorser that a hardcopycan be mailed to: AFRC/HCX, 255 Richard Ray BLVD. suite 111, Robins AFB, GA 31098. Electronic copiescan be sent to [email protected].

(6) ENROLLMENT VERIFICATIONIt must verifying full time / MDiv / 72 semester hours minimum. Application may be started with an acceptanceletter, however, attendance verification in AFRISS-R is necessary before package is submitted.

URE DOC NTSIncludes Chaplain Candidate Statement of Understanding, Consent To Publication of Personal Data,Understanding of Accelerated Appointment, and Declaration of Religious Consent.

PLICATION FOR READY RESERVE ASSIGNMENT

Include all colleges attended sent directly from registrar to recruiter. Must show degree granted. Assureaccreditation of school by viewing it on www.chea.org. In addition, if you have completed at least onesemester/quarter of seminary please request a current transcript.

(11) WAIVERSRequest as needed.

ly)The following items are needed in order to set up an interview:

Item 1. PERSONAL ESSAY Item 2. RESUME Item 5. DD FORM 2088, STATEMENT OF ECCLESIASTICAL ENDORSEMENT Item 10. TRANSCRIPTS

Once the above items have been received, contact Ch Hunt or Ch Spitzer for a QC. Once QC’d they will notate AFRISS. The Recruiter then contacts Ch Sarah Schechter ([email protected]) to set up the interview.

Y

( )

(3) CHAPLAIN CANDIDATE TRAINING RECORD

( )

(5) DD

ENROLLMENT(6) VERIFICATION

URE DOC NTS

PLICATION FOR READY RESERVE ASSIGNMENT

WAIVERS(11)

ly)

UUSAF Reserve Chaplain Corps Checklist Item Descriptions

Page 3 of 3Last updated 5 December 17

AND A EY

T SERVICE DOCUMENTSAll prior and current military documents cited below.

(16a) DD FORM 214 (If Separated from Active Duty, Reserve), FORM 22 (If discharged from guard), And ALL PRIOR SERVICE DOCUMENTS that are applicable.

8 (other branches, active or reserve)

D Provide as PDF scans. Provide all evaluations from other branches if Prior.

AND A E

T SERVICE DOCUMENTS

FORM(16a) DD 214

8

D

DOCUMENTS REQUIRED IN UFT/ABM APPLICATION

Table 1, If applicant is:

1 2 3 4 5

A Civilian (non-prior service) Y An Air Force Reserve Officer or Active Duty Officer Y An Air Force Reserve Airman or Active Duty Airman Y An Inter-service Officer Transfer Y An Inter-service Enlisted Transfer Y

A AF Form 56, Application and Evaluation for Training Leading to a Commission in the United States Air Force (See Note 1)

X X X X X

B College transcripts X X X X X C DD Form 368, Request for Conditional Release (if

applicable) X X

D DD Form 785– Record of Disenrollment from Officer Candidate –Type Training (if applicable) (See Note)

X X X

E Flying Class I (for pilot)/IA (for CSO)/III (for ABM), Medical Flight Screening (pilot only)

X X X X X

F AF Form 2030, USAF Drug and Alcohol Abuse Certification

X X X

G AF Form 24, Application for Appointment as Reserves of the Air Force or USAF without Component

X X X X

H AF Form 215, Aircrew Training Candidate DataSummary

X X X X X

I AF Form 1288, Application for Ready Reserve Assignment

X X X X X

J Last Page of Civilian Flight Log Book (if applicable) X X X X X K DD Form 214, Certificate of Release or Discharge from

Active Duty (if applicable) X X X X

L Federal Aviation Administration pilot license (photocopy of license front and back) (if applicable)

X X X X X

M Security Clearance Information X X X X N Reserve Service Commitment Statement X X X X X O Pilot Candidate Selection Method (PCSM) score

printout (UPT applicants only) X X X X X

P Air Force Officer Qualifying Test (AFOQT) Scores X X X X X Q Wing/CC Letter of Recommendation (Group/CC, if

applicable) X X X X X

R Additional Letters of Recommendation X X X X X S Resume´ X X X X X T AF Form 910, Enlisted Performance Report (AB thru

TSgt) (if applicable) X X

DOCUMENTS REQUIRED UFT/ABM APPLICATIONIN

Table 1,

U AF Form 911, Enlisted Performance Report (MSgt thru CMSgt) (all, if applicable)

X X

V AF Form 707, Officer Performance Report (Lt thru Col) (all, if applicable)

X X

W Air Force Fitness Test Score (Air Force Fitness Management System printout) (if applicable)

X X

X Letters to the Board (if applicable) (See Note 3) X X X X X

Notes 1. Applicants must designate in Block 7D (Rated Line Categories) their preference for

“Pilot,” “Navigator,” or “Air Battle Manager.” Applicants will meet the board as acandidate for all positions selected. Applicants must also select “Yes” in block 7D as avolunteer for flying duty. If “Yes” is selected in Block 11A and a DD Form 785 wasgenerated as a result of the disenrollment, the applicant must include a letter to the boardexplaining the circumstances of the disenrollment.

2. AF Form 215, page 1, block 11a: current Air Force service members must include mostrecent PFT score; Block 20: Wing/CC; Block 21 NAF/CC if a waiver or ETP is required

3. Applicants should include letters to the board to address irregularities or unusualcircumstances in their application. Letters are required if the applicant is requesting amoral waiver or DD Form 785 waiver. Any format is allowed.

Upload ALL document in AFRISS-TF separate files: Upload by type example AF Form 24

Lastname_AF24 Lastname_AF215 Lastname_Wing CC Recommendation Lastname_Resume Lastname_Recommendations Lastname_Letter to Board

Upload ALL document in AFRISS-TF separate files: p24Upload by type example AF Form

1.

2.

3.

INSTRUCTIONS FOR COMPLETING DD FORM 2807-2, ACCESSIONS MEDICAL PRESCREEN REPORT

1. This form is to be completed by each individual who requires medical processing in accordance with Department of Defense Instruction (DODI) 6130.03, “Physical Standards for Appointment, Enlistment, or Induction” and DODI 1304.02, “Accession Processing Data Collection Forms.” This form must be completed by the applicant with the assistance of the recruiter, parent(s), or guardian, as needed.

6. MEPS Chief Medical Officers (CMOs) may locally modify the above instructions and instruct recruiters on what supporting medical documents they require to complete the DD Form 2807-2 medical prescreen review, if doing so enhances the efficiency of medical processing and is consistent with DODI 6130.03 and USMEPCOM guidance.

7. If all attempts to obtain required substantiating and supporting medical documents fail, the recruiter must contact the MEPS medical department for guidance prior to submitting an incomplete medical prescreen packet.

2. Replaces the existing medical prescreen form (DD Form 2807-2, AUG 2011). Additional questions have been added to improve its usefulness to the accessions medical pre-screening process. The questions are intended to provide the U.S. Military Entrance Processing Command (USMEPCOM) with health history information necessary to identify conditions commonly related to medical causes for separation during basic and follow-on training (per P.L. 105-85, Div. A, Title V, S 532).

3. Use of medical history information facilitates efficient, timely, and accurate medical processing of individuals applying for Service in the United States Armed Forces or United States Coast Guard. Positive responses do not automatically result in disqualification but are necessary to prompt further explanation that will be used to determine medical qualification. Medical history information assists USMEPCOM medical personnel in the medical prescreening of applicants. Accurate responses to all questions are critical and all positive responses must be fully explained. Applicant responses to questions may be verified using electronically obtained medical history by the USMEPCOM. Medical history information will be used by the Department of Defense for continuity of care purposes if and when an applicant accesses into the Armed Forces or Coast Guard. Supporting medical information in the form of historical medical records may also be attached to the Service member’s medical record. Medical history information collected by the USMEPCOM during accession medical processing will serve as the foundation for a Service member’s lifecycle medical treatment record.

4. The completed DD Form 2807-2 along with all substantiating and supporting medical documents must be delivered to USMEPCOM for review prior to scheduling the applicant for medical examination. All documents must be submitted for review in accordance with standards below. After review, the Military Entrance Processing Station (MEPS) will notify the Recruiting Service of the applicant’s status. - 1 processing day prior for applicants with no positive medical history (all items marked “NO” with the exception of items 9 (glasses/contacts), 11 (defective color vision), and 20 (braces) which can be “YES”). - 2 processing days prior; for applicants with ANY positive medical history (other than those noted above) and 5 OR LESS single-sided pages of supporting medical documents. - 3 processing days prior; for applicants with ANY positive medical history (other than those noted above) and MORE THAN 5 single-sided pages of supporting medical documents.

Secure electronic submission is preferable; if not feasible bring/mail to the nearest MEPS which can be found at http://www.mepcom.army.mil/battalions/index.html. All supporting medical documentation must be present with the DD Form 2807-2 to meet the above timeframes for review. After review by a USMEPCOM provider, appropriate processing notification will be made.

5. If an applicant has been seen by any Health Care Provider (HCP) and/or has been hospitalized for any reason, medical records/documentation must be obtained and submitted along with a medical release to USMEPCOM. Provide all medical documents via secure electronic submission (if possible) to the nearest MEPS. If hand-carried or mailed, ensure they are sealed in an envelope marked: “CONFIDENTIAL: MEPS MEDICAL DEPARTMENT". 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/HCP including:

(1) office or clinic assessment and progress notes, including the initial assessment documents, subsequent evaluation and treatment documents, and record of date when released from care to full, unrestricted activity; (2) emergency room (ER) report(s); (3) study reports (e.g. x-ray, magnetic resonance imaging (MRI), Computerized Tomography (CT), etc.); (4) procedure reports (e.g., arthroscopy, electroencephalogram (EEG; brain wave test), echocardiogram (ultrasound of the heart), etc.); (5) pathology reports (e.g., tissue specimens sent to lab for microscopic diagnosis, abnormal PAP smear cytology, etc.); (6) specialty consultation records (e.g., neurologist, cardiologist, OB/GYN, gastroenterologist, orthopedic surgeon, pulmonologist, allergist, etc.).

b. If the applicant was hospitalized, obtain a copy of the inpatient hospital record, to include (if any): ER report, admission history and physical, study reports, procedure reports, operative report (example: surgery to bone or joint), pathology report, specialty consultation reports, and discharge summary. c. If an applicant has been diagnosed or treated for any attention disorder (Attention Deficit Disorder (ADD), Attention Deficit Hyperactivity Disorder (ADHD), etc.), academic skills or perceptual defect, or had an Individualized Education Plan or 504 Plan, call/contact the MEPS medical department for additional instructions. d. Obtain any and all documents relating to any 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 problems, depression, treatment or rehabilitation for alcohol, drug, or substance abuse.

DD FORM 2807-2, MAR 2015 PREVIOUS EDITION IS OBSOLETE. Page 1 of 7 PagesAdobe Designer 9.0

ACCESSIONS MEDICAL PRESCREEN REPORTOMB No. 0704-0413 OMB approval expires Oct 31, 2017

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 the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Directives Division, 4800 Mark Center Drive, Alexandria, VA 22350-3100 (0704-0413). 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.

PRIVACY ACT STATEMENTAUTHORITY: 10 U.S.C. 504, 505, 507, 532, 978, 1201, 1202, and 4346; and E.O. 9397 (SSN). 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): DoD Blanket Routine Uses found at http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx apply to the use of this data. 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 confinement or $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 may be subject to prosecution under the Uniform Code of Military Justice or to administrative separation proceedings for discharge, and could receive a less than honorable discharge.”

4. SOCIAL SECURITY NUMBER 3. DATE OF BIRTH (YYYYMMDD) 1. LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)

5. HEIGHT (inches) 9. DATE (YYYYMMDD)

12. USUAL OCCUPATION

8. SERVICE AND COMPONENT (X as applicable)

10. PURPOSE OF EXAMINATION (X as applicable) 11. POSITION (If a current Federal Employee) (Job Title, Grade, Component)

7. MAX WEIGHT (lbs.)

6. WEIGHT (lbs.)

2. AGESECTION I - APPLICANT

SECTION II - MEDICAL HISTORY. Initial each item "Yes" or "No". All "Yes" items must be fully explained in Section III (Pages 4 and 5).

Navy

Army

USAF

Enlistment U.S. Service Academy

ROTC Scholarship

Other (Specify)

Commission

Retention

1. Double vision

8. Any other eye condition, injury or surgery

10. Loss of vision in either eye

11. Color vision deficiency or color blindness

7. Strabismus or "lazy eye" or any surgery to correct these

6. Glaucoma

5. Night blindness

4. Eye surgery to improve vision (RK, PRK, LASIK, etc.)

3. Cataracts or surgery for cataracts

2. Detached retina or surgery to repair a detached retina

USCG

Other:

USMC

National Guard

Reserve Component

Regular

CURRENTLY HAVE OR ANY HISTORY OF:EYES

22. Asthma

27. Used inhaler(s) or steroids for breathing problem(s)

30. History of chest, chest wall, or breast surgery

29. Collapsed lung or other lung condition

28. Chronic cough or frequent coughing at night

26. Other breathing problems worsened by exercise, weather, pollens, etc.

25. Bronchitis

24. Shortness of breath

23. Wheezing

LUNGS, CHEST WALL, PLEURA, AND MEDIASTINUM

21. Tooth or gum problems (other than cavities)

12. Perforated ear drum or tubes in ear drum(s)

14. Loss of balance or vertigo

13. Ear surgery, to include mastoidectomy or repair of perforated ear drum

EARS

31. Heart murmur, valve problem or mitral valve prolapse

36. Any other heart problems

35. An abnormal electrocardiogram (EKG)

34. Pain or pressure in the chest

33. Heart surgery

32. Palpitation, pounding heart or abnormal heartbeat

HEART

37. Stomach, esophageal or intestinal ulcer

45. Rectal disease, hemorrhoids, or blood from the rectum

47. Bariatric surgery (weight loss surgery)

46. Hemorrhoid surgery

42. Rupture/hernia

44. Chronic or recurrent intestinal problem of the small or large bowel such as Irritable Bowel Syndrome, Crohn's disease, Ulcerative Colitis, or Celiac disease

43. Surgery to remove or repair a portion of the intestine or spleen (other than the appendix)

41. Jaundice (except neonatal) or hepatitis (liver disease)

40. Gall bladder trouble or gallstones

39. Frequent indigestion or heartburn

38. Difficulty swallowing

ABDOMINAL ORGANS AND GASTROINTESTINAL SYSTEM

15. Hearing loss or wear a hearing aid

HEARING

16. Ear, nose, or throat trouble including tonsillectomy

19. Any surgery of your face, mandible or jaw

18. Absence of, or disturbance of sense of smell

17. Chronic sinus infections or recurrent nose bleeds

NOSE, SINUSES, MOUTH, AND LARYNX

9. Worn/wear contact lenses or glasses (Bring your contact lens kit and solution so you can remove contacts during vision testing, or for best results remove 72 hours prior. Bring your eyeglasses no matter how old they are.)

VISION

20. Do you wear dental braces or plan to wear braces? (If so, your orthodontist must submit a letter stating that active orthodontic treatment will be completed prior to active duty date: release form/ sample format can be found in the Recruiter's Medical Guide.)

DENTAL

NOYESCURRENTLY HAVE OR ANY HISTORY OF:YES NO

Page 2 of 7 PagesDD FORM 2807-2, MAR 2015

SOCIAL SECURITY NUMBER (Last 4)LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)

SECTION II - MEDICAL HISTORY (Continued). Initial each item "Yes" or "No". All "Yes" items must be fully explained in Section III.

48. A change of menstrual pattern (other than pregnancy)

50. Any abnormal PAP smear(s)

52. Diagnosed with endometriosis or ovarian cysts

54. Sexually transmitted disease (syphilis, gonorrhea, chlamydia, genital warts, herpes, etc.)

59. Sexually transmitted disease (syphilis, gonorrhea, chlamydia, genital warts, herpes, etc.)

53. Evaluation, treatment or surgery for any other gynecological (female) disorder

51. Date of last PAP smear (YYYYMMDD)

55. First day of last menstrual period (YYYYMMDD)

49. Pregnancy, abortion or miscarriage

CURRENTLY HAVE OR ANY HISTORY OF:FEMALES ONLY:

56. Missing a testicle, testicular implant, or undescended testicle

58. Prostate problems

57. Variocele, hydrocele, or any scrotal mass, swelling or pain

MALES ONLY:

60. Missing a kidney

65. Bedwetting or treatment for bedwetting (after childhood)

66. Hernia

64. Painful or difficult urination

63. Blood or protein in urine

62. Kidney or urinary tract surgery of any kind

61. Kidney stone, infection or disease

URINARY SYSTEM

ENDOCRINE AND METABOLIC

67. Recurrent back pain or back problem

71. Abnormal curvature of your spine (any part)

70. Back or neck surgery

69. Recurrent neck pain

68. Herniated disk

SPINE AND SACROILIAC JOINTS

72. Painful shoulder, elbow, wrist, hand or fingers

73. Dislocated shoulder, elbow, wrist, hand or fingers

UPPER EXTREMITIES

78. Bone, joint, or other orthopedic deformity

79. Loss of finger or toe, or extra finger or toe

87. Any need to use corrective devices such as prosthetic devices, knee brace(s), back support(s), lifts or orthotics

88. Any other orthopedic, muscle, or sports injury problems

86. Pain or swelling at the site of an old fracture

85. Plate(s), screw(s), rod(s) or pin(s) in any bone

84. Surgery on any joint/bone (including arthroscopy)

83. Any swollen joint(s)

82. Arthritis, rheumatism, or bursitis

81. Impaired use of arms, hands, legs, or feet (any reason)

80. Loss of the ability to fully flex (bend) or fully extend a finger, toe, or other joint

MISCELLANEOUS CONDITIONS OF THE EXTREMITIES

LEARNING, PSYCHIATRIC, AND BEHAVIORAL131. Evaluated or treated for Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD)

133. Diagnosed with a learning disorder, to include dyslexia

135. Seen a psychiatrist, psychologist, social worker, counselor or other professional for any reason (inpatient or out-patient) including counseling or treatment for school, adjustment, family, marriage, divorce, depression, anxiety, or treatment of alcohol, drug or substance abuse (Applicant or recruiter will request sealed medical supporting documents from health care providers marked "CONFIDENTIAL: MEPS MEDICAL DEPART- MENT" and submit directly to MEPS medical personnel.)

134. Received counseling of any type

132. Taken (or taking) medication, drugs, or any substance to improve attention, behavior, or physical performance

SLEEP DISORDERS

89. High or low blood pressure

90. Raynaud's phenomenon or disease

92. Pulmonary embolism (blood clot in lung)

91. Deep Vein Thrombosis (blood clot; leg or elsewhere)

VASCULAR

74. Foot trouble (e.g., pain, corns, bunions, warts, ingrown toenails, etc.)75. Knee trouble (e.g., locking, giving out, or ligament injury, etc.)

77. Dislocated hip, knee, ankle, foot or toes

76. Painful hip, knee, ankle, foot or toes

LOWER EXTREMITIES

93. Acne or psoriasis

96. Large or painful scars

97. Any other skin problems

95. Atopic dermatitis

94. Eczema

SKIN AND CELLULAR

98. Anemia

99. Blood clots requiring blood thinner medicine

101. Prolonged bleeding (after an injury or tooth extraction)

102. Any other blood or circulation problems

100. Absence or removal of the spleen

BLOOD AND BLOOD FORMING TISSUES

103. Adverse reaction to medication (describe reaction in Section III)

105. Allergy to common foods (milk, eggs, fish, meat, etc.)

111. Car, train, sea, or air sickness

110. Disorder(s) of your immune system (including HIV)

109. Malaria

114. Diabetes or told that you should be tested for diabetes

113. High or low blood sugar

112. Thyroid trouble or goiter

NEUROLOGIC

117. Taking medication to prevent headaches

116. Frequent or severe headaches, including migraines

115. Cerebrovascular incident (stroke)

126. Dizziness or fainting spells

127. Any other neurologic problems

125. Seizures, convulsions, epilepsy or fits

124. Meningitis, encephalitis, or other neurological problems

130. Sleep apnea or severe snoring

129. Frequent trouble sleeping

128. Sleepwalking or narcolepsy

123. Paralysis

122. Loss of memory or amnesia, or neurological symptoms

121. A period of unconsciousness or concussion

120. A head injury, memory loss, or amnesia

119. A skull fracture

118. Lost time from work or school due to frequent or severe headaches

108. Positive test for tuberculosis (PPD or blood test)

107. Tuberculosis or lived with someone who had tuberculosis

106. Allergy to wool, latex, or other material

104. Adverse reaction to serum, insect stings, or tree nuts

SYSTEMIC

NOYESCURRENTLY HAVE OR ANY HISTORY OF:YES NO



SECTION II - MEDICAL HISTORY (Continued). Initial each item "Yes" or "No". All "Yes" items must be fully explained in Section III.

SECTION III - APPLICANT COMMENTS. Explain all "Yes" answers to questions 1 - 164 above. Begin with the Item Number. Describe answer(s) fully: provide date(s) of problem(s)/condition(s); provide names of Health Care Providers (HCPs), Clinic(s) and/or Hospital(s) along with the City and State; explain what was done (e.g., evaluation and/or treatment); and describe your current medical status. Attach additional sheet(s) if necessary and sign and date each additional page. Obtain and attach copies of applicable medical evaluation and treatment records.

CURRENTLY HAVE OR ANY HISTORY OF: NOYESCURRENTLY HAVE OR ANY HISTORY OF:YES NOLEARNING, PSYCHIATRIC, AND BEHAVIORAL (Continued)

141. Anorexia, bulimia, or other eating disorder

145. Used illegal drugs or abused prescription drugs

146. Have you been evaluated, treated, or hospitalized for substance abuse, addiction or dependence (including illegal drugs, prescription medications or other substances)147. Have you been evaluated, treated, or hospitalized for alcohol abuse, dependence, or addiction

149. Any other learning, psychiatric, or behavioral problems

148. Post-traumatic Stress Disorder or excessive stress requiring counseling and/or medication following a traumatic experience

144. Have you ever attempted or considered suicide

143. Have you ever purposely cut or harmed yourself

142. Habitual stammering or stuttering

150. Tumor, growth, cyst, or cancer of any type

TUMORS AND MALIGNANCIES

151. Cold injury, frostbite or cold intolerance

152. Heat injury, heat stroke or heat intolerance

MISCELLANEOUS

153. Are you taking any medications, to include over the counter medications (OTCs), vitamin, herbal, or nutritional supplements (If "yes", list all in Section III.)

154. Any recent unexplained gain or loss of weight155. Artificial or replacement body part (eye, bone, palate, hip, knee, joint, leg, arm, etc.)156. Have you ever had any illness or injury other than those already noted? (If "yes", specify when, where and give details in Section III.)

SUPPLEMENTAL QUESTIONS

157. Have you ever been treated in an Emergency Room? (If "yes", explain in Section III.)

160. Have you ever been rejected for military Service for any reason? (If "yes", give date and reason in Section III.)

161. Have you ever been discharged from the military Service for any reason? (If "yes", give date, reason, and type of discharge, whether honorable, other than honorable, for unfitness or unsuitability in Section III.)

162. Have you ever been refused employment or been unable to hold a job or stay in school because of any of the following: (If "yes", answer a - d below and give reasons in Section III.)

163. Applied for and/or received disability evaluation and/or compensation for an injury or other medical conditions (If "yes", provide details in Section III.)

164. Have you ever been denied life insurance? (If "yes", provide reason(s) in Section III.)

a. Sensitivity to chemicals, dust, sunlight, etc.

d. Other medical reasons

c. Inability to stand, sit, kneel, lie down, etc.

b. Inability to perform certain motions

159. Have you ever had, or have you been advised to have any operations or surgery? (If "yes", describe and give age at which occurred in Section III.)

158. Have you ever been a patient in any type of hospital (including being kept overnight)? (If "yes", specify when, where, why, and name of doctor and complete address of hospital in Section III.)

SUPPLEMENTAL QUESTIONS (Continued)


140. Nervous trouble of any sort (anxiety or panic attacks)

139. Been evaluated or treated, either with medication or counseling, for a mental condition, depression or excessive worry

136. Been expelled or suspended from school

138. Been arrested or other encounters with law enforcement

137. Been kicked out or removed from your home


SECTION III - APPLICANT COMMENTS (Continued).

SECTION IV - HEALTH CARE PROVIDER/INSURANCE CARRIER CONTACT INFORMATION: Current Primary Care Physician(s)/Practitioner(s) and/or Clinic(s) where care is received and Current/Previous Insurance Carrier(s) information. Attach additional sheets if necessary.

c. TELEPHONE (Include Area Code)b. ADDRESS (Include ZIP Code)a. NAME(S)1. CURRENT PRIMARY CARE PHYSICIAN(S)/PRACTITIONER(S) AND/OR CLINIC(S)

c. TELEPHONE (Include Area Code)b. ADDRESS (Include ZIP Code)a. NAME(S)2. PREVIOUS PRIMARY CARE PHYSICIAN(S)/PRACTITIONER(S) AND/OR CLINIC(S)

c. TELEPHONE (Include Area Code)b. ADDRESS (Include ZIP Code)a. NAME(S)3. CURRENT INSURANCE AND/OR PHARMACY BENEFIT MANAGER(S)

c. TELEPHONE (Include Area Code)b. ADDRESS (Include ZIP Code)a. NAME(S)4. PREVIOUS INSURANCE AND/OR PHARMACY BENEFIT MANAGER(S)



SECTION V - APPLICANT VALIDATION, AUTHORIZATION AND SIGNATURE

STOP AND READ: THE FOLLOWING STATEMENTS APPLY TO SIGNATURES IN SECTION V (BELOW)

l

l

l

l

l

l

l

l

I (we) , the undersigned:

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.

Authorize and understand that a physical examination is part of the accession evaluation, may require several visits to the Military Entrance Processing Station (MEPS), and that I will have blood work and/or other medical tests, procedures and/or specialty consultations performed as part of my processing. I understand that the results of the examination, tests, and consults will be reviewed and considered as part of my application file and are not performed as part of an individual healthcare treatment plan. The MEPS medical staff are not my healthcare providers. If I do not receive notice of an abnormal test or consult, I am not to assume that the results are normal. Furthermore, if any test or consult results are abnormal, I am responsible for obtaining those results from the MEPS and for any necessary follow-up evaluations and/or treatment. If I am notified to return to the MEPS to discuss medical results, it is my responsibility to take quick action to return to the MEPS to speak with the Chief Medical Officer (CMO). Any concerns that I have about my health and healthcare are my responsibility to address with my personal healthcare provider(s).

Understand that I must provide required documentation regarding my health history which, upon my accession, will become part of my Service member lifecycle medical treatment record.

Authorize the Department of Defense (DoD) to request holders of medical/behavioral health data (including but not limited to healthcare providers, clinics, hospitals, insurance companies, pharmacy benefit managers, pharmacies, health information exchanges, and federal and state agencies) to release to the DoD medical authority a complete transcript of my health data for purposes of processing my application for Military Service. I also authorize holders of my health data to report to the DoD whether any data they hold or have held about me has been amended or restricted. I agree that all personal information or data disclosed by myself or others on my behalf with my consent during this process may be further disseminated as needed during the accession process and that my medical information is no longer protected by federal Health Insurance Portability and Accountability Act (HIPAA) Privacy Rules.

Authorize release of records and information relating to grades, performance, individual education plans, and disciplinary proceedings. Under the Family Educational Rights and Privacy Act (FERPA) USMEPCOM is authorized to receive all my education/disciplinary records for evaluation of my acceptability for Service in the Armed Forces.

Understand that I have the right to refuse to sign this authorization but also understand that failure to do so may cause me to be found disqualified for further processing.

Understand this authorization will expire two years from the date of the signature below or sooner if written request is received by USMEPCOM Staff Judge Advocate’s Office. I have the right to revoke this authorization in writing, except to the extent that the DoD has acted in reliance on this information.

c. DATE SIGNED (YYYYMMDD)b. SIGNATUREa. NAME (Last, First, Middle Initial)

2. PARENT OR GUARDIAN SIGNATURE IS MANDATORY FOR MINOR APPLICANT, SIGNATURE IS OPTIONAL IF APPLICANT IS OF AGE

b. DATE SIGNED (YYYYMMDD)a. SIGNATURE1. APPLICANT

d. DATE SIGNED (YYYYMMDD)c. SIGNATUREb. RECRUITER IDENTIFICATION NUMBER

a. NAME (Last, First, Middle Initial)

3. RECRUITING REPRESENTATIVE: (If a representative was used) I certify all information is complete and true to the best of my knowledge.



SECTION VI - MEDICAL PROVIDER'S SUMMARY AND DESCRIPTION OF PERTINENT INFORMATION: Review and comment on all medical records, electronically provided medical history information, and other electronic data available in the Department of Defense Accessions Processing System. Medical providers may also develop any additional medical history deemed important and record significant findings here or by interview and document them on DD Form 2808, "Report of Medical Examination". Attach additional sheet(s) if necessary.COMMENTS:

SECTION VII - MEDICAL PROVIDER'S PRESCREEN DETERMINATION BASED ON AVAILABLE INFORMATION:

1.a. DATE (YYYYMMDD)

h. DATE (YYYYMMDD)

b. MEDICAL PROCESSING STATUS

ON EXAM: i. PROVIDER INITIALSd. *AE g. *OEf. *MEe. *REc. NPSb. PSN INCOMa. PSN COMP

PA PULHES SMWRA INPUTCONDITIONICDMETR PNJRJPHPRWd. PROVIDER

INITIALSc. IF NOT WITHIN STANDARDS:

KEY: PA = Processing Authorized; PRW = Processing Requested by SMWRA; PH = Processing Hold; RJ = Return Justified; METR = Medical Evaluation and/or Treatment Records; PNJ = Processing Not Justified; ICD = International Classification of Disease Code; PULHES = P (Physical Capacity), U (Upper Extremities), L (Lower Extremities), H (Hearing), E (Eyes), S (Psychiatric); SMWRA = Service Medical Waiver Review Authority.

KEY: PSN = Prescreen; COMP = Complete; INCOM = Incomplete; NPS = Not Prescreened; AE = Applicant Error; RE = Recruiter Error; ME = MEPS Error; OE = Other Source of Error.

2. *FOR MEPS USE ONLY:

3. AUTHORIZING MEDICAL PROVIDER 4. NUMBER OF ADDITIONAL SHEETS SUBMITTED

c. DATE SIGNED (YYYYMMDD)b. SIGNATUREa. NAME (Last, First, Middle Initial)


Instructions for Filling out the 680 Request for Examination

Please Follow These Directions Exactly or Your Form Will Be Returned for Corrections

Start at Letter B. and continue only as indicated here

A. SKIP

B. Check Yes or No, please leave number of days blank

C. SKIP

D. Males Only, Enter Your SSS Number Here Click here to find SSS Number

1. Enter your social security number

2. Last Name, First Name, Middle Name

3. Street Address, City, County, State, US, Zip code

4. Same as 3

5. Check appropriate

6. Check appropriate

7A/B. Check appropriate

8. Married or Single

9. 0-9

10. YYYYMMDD (Example 19841103)

11-13. Does not need to be changed

14. Check appropriate, then State, Number, Expiration Date (PA, 123456, 20251103)

15. City, State, Country

16-24. SKIP

25. Check appropriate A or B, enter approximate information, SIGN F, enter social

security number and date

26. Sign here

27. Sign here

APPLICANT SSN – Enter Social Security Number (example XXX-XX-XXXX)

YOU SHOULD HAVE SIGNED THREE TIMES 25F, 26 and 27

https://utilities.sss.gov/OnlineRCV/mVerification.aspx/

The public reporting burden for this collection of information is estimated to average 22 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 Headquarters, U.S. Military Entrance Processing Command, Operations Directorate, 2834 Green Bay Road, North Chicago, IL 60064-3094.

FOR USE OF THIS FORM, SEE USMEPCOM REG 680-3 FOR OFFICIAL USE ONLY

REQUEST FOR EXAMINATION THE INFORMATION PROVIDED CONSTITUTES AN OFFICIAL STATEMENT.

OMB No. 0704-0173 OMB approval expires Sep 30, 2017

A. SERVICE PROCESSING FOR

1. SOCIAL SECURITY NUMBER

3. CURRENT ADDRESS (Street, City, County, State, Country, ZIP Code)

B. PRIOR SERVICE C. SELECTIVE SERVICE CLASSIFICATION D. SELECTIVE SERVICE REGISTRATION NUMBER

NUMBER OF DAYS

Yes

- -

No

Yes

NoYes

NoYes

NoYes

NoFULL

Yes

No

1st 2nd

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

4. HOME OF RECORD ADDRESS (Street, City, County, State, Country, ZIP Code)

f. ALIEN REGISTRATION NUMBER (As applicable)

e. NON-IMMIGRANT FOREIGN NATIONAL (Specify)

d. IMMIGRANT ALIEN (Specify)

c. U.S. NON-CITIZEN NATIONALb. U.S. NATURALIZED

(2) BORN ABROAD OF U.S. PARENT(S)(1) NATIVE BORN

a. U.S. AT BIRTH ( If this box is marked, also X (1) or (2))

5. CITIZENSHIP (X one)

b. FEMALE a. MALE

6. SEX (X one) 7.a. ETHNIC CATEGORY (X one)

7.b. RACIAL CATEGORY (X all that apply)

(1) HISPANIC OR LATINO (2) NOT HISPANIC OR LATINO

(5) WHITE

(4) NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

(3) BLACK OR AFRICAN AMERICAN

(2) ASIAN(1) AMERICAN INDIAN/ALASKA NATIVE

9. NUMBER OF DEPENDENTS

8. MARITAL STATUS (Specify)

(If Yes, specify)

13. PROFICIENT IN FOREIGN LANGUAGE (X one)12. EDUCATION (Yrs/Highest Ed Gr completed)11. RELIGIOUS PREFERENCE (Optional)10. DATE OF BIRTH (YYYYMMDD)

15. PLACE OF BIRTH (City, State, and Country)14. VALID DRIVER'S LICENSE (X one) (If Yes, list State, number, and expiration date)

(X one)b. ENLIST UNDER STUDENT TEST

(X one)a. ASVAB REQUIRED TO ENLIST?16. APTITUDE:

2.1.f. PREVIOUS TEST DATES (YYYYMMDD)

2.1.e. PREVIOUS TEST VERSIONS

6 MONTH RETESTIMMED RETEST AUTHORIZED

2ND RETEST1ST RETESTd. RETEST TYPE

CONFIRMATIONSPECIALINITIAL

c. TEST TYPE

19. TEST ADMINISTRATOR SIGNATURE18. TEST ADMINISTRATOR SSN/IDb. STATION ID17.a. RECRUITER ID/SSN

c. DATE LAST FULL MEDICAL EXAM (YYYYMMDD)

b. EXAM TYPEa. MEPS MEDICAL EXAM REQUIRED TO ENLIST?20. MEDICAL:OTHERRE-EXAM

CONSULTSPECIAL

INSPECT (X one)

NoYes

If Yes, type/organization:

ID Number:

Photo ID? (X one)

21. APPLICANT'S SIGNATURE 22. MIRS CODINGINTDATEINTDATESTWKID

(Signature of Applicant)

23. APPLICANT CERTIFICATION IN PRESENCE OF TEST ADMINISTRATOR I certify that I am the person identified on this form:

24. RIGHT THUMBPRINT RIGHT THUMBPRINT, FIRST ATTEMPT (Affix thumbprint with thumbnail pointed to the left.)

25. APPLICANT CERTIFICATION IN PRESENCE OF RECRUITING PERSONNEL I certify that I am the person identified on this form and 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:

(School, City, and State)

at

(Most Recent Date Tested)

c. Request for student test scores (high school look-up)

(School, City, and State)

at

(Most Recent Date Tested)

b. I was tested with the ASVAB on or about

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.

(13 Digit Code)OR

/

(High School)

e. Current or last high school attended

d. Yes, I want to keep my AFQT scores from the student test listed in "c" above.

(Date)(Social Security Number)

/ /

(Signature of Applicant)

(Date)

//

(Signature of Recruiter (or representative, if authorized)) (Printed/Typed Name of Recruiter or representative)

(Recruiter ID/SSN)

/

(Bn, NRD, Sq or RS Location)

/

(Local Recruiting Activity)

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

f.IF SECOND ATTEMPT IS REQUIRED: Turn form over (Top of form on the bottom). Affix right thumbprint on upper right corner, thumbnail pointed to the left.

MEDICAL RECORDS RELEASE AUTHORITY: I request and authorize individuals, businesses or organizations to release to Representatives of USMEPCOM my complete medical records. This release of medical information is for the sole purpose of further evaluation of my medical acceptability into the Armed Services. Hard-copy records are to be obtained by me at no cost to the Government and made available for medical pre-screening review. USMEPCOM has my permission to access/obtain all electronic medical records for this purpose.

29. MEDICAL PROVIDER ADDRESS (Street, City, State, Country, ZIP Code)

27. APPLICANT'S CURRENT MEDICAL PROVIDER NAME (If none, sign your complete name to affirm you have no current medical provider):

28. MEDICAL INSURER ADDRESS (Street, City, State, Country, ZIP Code)

26. APPLICANT'S CURRENT MEDICAL INSURER NAME (If none, sign your complete name to affirm you have no current medical insurer):

30. CERTIFICATION BY RECRUITING PERSONNEL 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 applicant's signature:

APPLICANT SSN

USMEPCOM FORM 680-3A-E, JUN 2015 PREVIOUS EDITION IS OBSOLETE. Adobe Designer 9.0

Read Privacy Act Statement on back before completing form.

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USMEPCOM FORM 680-3A-E (BACK), JUN 2015

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; 504, Persons Not Qualified; 505, Regular components: qualifications, term, grade; and 12102, Reserve Components: Qualifications; 14 U.S.C. 351, Enlistments; term, grade; and 632, Functions and powers vested in the Commandant; DoDI 1304.2, Accession Processing Data Collection Forms; DoDI 1304.26, Qualification Standards for Enlistment, Appointment, and Induction; AR 601-270, OPNAVINST 1100.4C Ch-2, AFI 36-2003_IP, MCO 1100.75E, and COMDTINST M 1100.2E, Military Entrance Processing Station (MEPS); AR 601-210, Active and Reserve Components Enlistment Program; AFPD 36-20; and E.O. 9397, as amended (SSN). PRINCIPAL PURPOSE(S): Military recruiters use the information you provide on this form to collect additional information from the individuals, schools, and employers you list so that we can determine if you meet recruitment standards. If you do meet these standards and enlist, the information you provide on this form starts your Official Military Personnel File. During the recruiting process we use the information on this form to verify your identity. This form also contains a section where you are asked to provide your signed consent for your medical provider(s) to release your medical records to the DoD. While completed forms are covered by recruiting and official military personnel file SORNs maintained by each of the Services the primary SORN may be found at: http://dpcld.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/570077/a0601-270-usmepcom-dod.aspx ROUTINE USE(S): Information is disclosed to the Selective Service System (SSS) to update the SSS registrant database and may also be disclosed to local and state Government agencies for compliance with laws and regulations governing control of communicable diseases. The specific DoD Blanket Routine Uses identified below (and also found at http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx) also apply to this collection. 01. Law Enforcement Routine Use: If a system of records maintained by a DoD Component to carry out its functions indicates a violation or potential violation of law, whether civil, criminal, or regulatory in nature, and whether arising by general statute or by regulation, rule, or order issued pursuant thereto, the relevant records in the system of records may be referred, as a routine use, to the agency concerned, whether federal, state, local, or foreign, charged with the responsibility of investigating or prosecuting such violation or charged with enforcing or implementing the statute, rule, regulation, or order issued pursuant thereto.

02. Disclosure When Requesting Information Routine Use: The DoD may disclose your information to a federal, state, or local agency maintaining civil, criminal, or other relevant enforcement information or other pertinent information, such as current licenses, if necessary to obtain information relevant to your enlistment request (ie., a DoD decision concerning the hiring or retention of an employee).

04. Congressional Inquiries Disclosure Routine Use: The DoD may disclose your record to your congressperson if your congressional office makes an inquiry at your request.

09. Disclosure to the Department of Justice for Litigation Routine Use: The DoD may disclose your record to the Department of Justice for the purpose of representing the Department of Defense, or any officer, employee or member of the Department in pending or potential litigation to which the record is pertinent.

12. Disclosure of Information to the National Archives and Records Administration Routine Use: The DoD may disclose your record to the National Archives and Records Administration for the purpose of records management inspections conducted under authority of 44 U.S.C. 2904 and 2906.15. Data Breach Remediation Purposes Routine Use: The DoD may disclose your record to an appropriate agency, entity, or person when (1) The DoD suspects or has confirmed that the security or confidentiality of the information in the system of records has been compromised; (2) the DoD has determined that as a result of the suspected or confirmed compromise there is a risk of harm to economic or property interests, identity theft or fraud, or harm to the security or integrity of this system or other systems or programs (whether maintained by the DoD or another agency or entity) that rely upon the compromised information; and (3) the disclosure made to such agencies, entities, and persons is reasonably necessary to assist in connection with efforts to respond to the suspected or confirmed compromise and prevent, minimize, or remedy such harm. DISCLOSURE: Voluntary. However, if you fail to provide the requested information you might not be able to enlist. Your Social Security Number is used during the recruiting process to conduct background screening (e.g., law enforcement, medical, or educational records checks; former employer checks, work status, etc.), keep all of your records together during the enlistment process, and ensure your test results are properly recorded. Applicable SORNs: Accession: U.S. Military Processing Command (http://dpcld.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/570077/a0601-270-usmepcom-dod.aspx) Army (http://dpcld.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/570085/a0600-8-104-ahrc.aspx) Navy (http://dpcld.defense.gov/Privacy/SORNsIndex/DODComponentArticleView/tabid/7489/Article/570316/n01131-1.aspx; http://dpcld.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/570318/n01133-2.aspx) Marine Corps (http://dpcld.defense.gov/Privacy/SORNsIndex/DODComponentArticleView/tabid/7489/Article/570628/m01133-3.aspx) Air Force (http://dpcld.defense.gov/Privacy/SORNsIndex/DODComponentArticleView/tabid/7489/Article/569780/f036-aetc-r.aspx) Coast Guard (http://www.gpo.gov/fdsys/pkg/FR-2008-12-19/html/E8-29845.htm) Official Military Personnel Files: Army (http://dpcld.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/570051/a0600-8-104b-ahrc.aspx; http://dpcld.defense.gov/Privacy/SORNsIndex/DODComponentArticleView/tabid/7489/Article/570052/a0600-8-104b-ngb.aspx) Navy (http://dpcld.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/570310/n01070-3.aspx) Marine Corps (http://dpcld.defense.gov/Privacy/SORNsIndex/DODComponentArticleView/tabid/7489/Article/569821/m01070-6.aspx) Air Force (http://dpcld.defense.gov/Privacy/SORNsIndex/DODComponentArticleView/tabid/7489/Article/569821/f036-af-pc-c.aspx) Coast Guard (http://www.gpo.gov/fdsys/pkg/FR-2008-12-19/html/E8-29793.htm)

STATEMENT OF ECCLESIASTICAL ENDORSEMENTOMB No. 0704-0190 OMB approval expires Dec 31, 2017

The public reporting burden for this collection of information is estimated to average 45 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 the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Directives Division, 4800 Mark Center Drive, Alexandria, VA 22350-3100 (0704-0190). 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 COMPLETED FORM TO THE ABOVE ADDRESS. RETURN COMPLETED FORM TO CHIEF OF CHAPLAINS (ITEM 3).

PRIVACY ACT STATEMENTAUTHORITY: 10 U.S.C. Sections 136, 533(a)(1), 643, 827, 3353(a)(1), and 5600(a)(1); DoD Directive 1304.19; DoD 1304.28; and E.O. 9397, as amended (SSN). PRINCIPAL PURPOSE(S): The information collected on this form is used to verify the professional and ecclesiastical qualifications of Religious Ministry Professionals for initial appointment or chaplains change of career status appointments as chaplains in the Military Services. This form is an essential element of a chaplain's professional qualifications and will become part of a chaplain's military personnel record. Completed forms are covered by recruiting and official military personnel file SORNs maintained by each of the Services. ROUTINE USE(S): The DoD "Blanket Routine Uses" found at http://dpclo.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx apply to this collection. DISCLOSURE: Voluntary. However, failure to provide the requested information may significantly delay the processing of this endorsement.

a. AS THE ECCLESIASTICAL ENDORSING AGENT AUTHORIZED TO REPRESENT (Name of religious organization) (Item 4a) , I HEREBY VERIFY THAT THE PERSON INDICATED IN PARAGRAPH

2, BELOW, IS CREDENTIALED AND QUALIFIED FOR AN APPOINTMENT WITHIN THE MILITARY CHAPLAINCY (as indicated in paragraph 2(j)(k) IN ACCORDANCE WITH THE STANDARDS CONTAINED IN DODI 1304.28. (Date of agent authorization - YYYYMMDD:)

1. ECCLESIASTICAL ENDORSING AGENT (To be completed by Endorsing Agent)

(4) ZIP CODE(3) STATE(2) CITYd. ADDRESS. (1) STREET (Include apartment or suite number)

c. E-MAIL ADDRESSb. TYPED OR PRINTED NAME (Last, First, Middle Initial)

h. DATE SIGNED (YYYYMMDD)

g. DATE OF BIRTH (YYYYMMDD)

g. SIGNATUREf. FAX NUMBER (Include Area Code)

e. TELEPHONE (Include Area Code)

NOYES2. PROSPECT INFORMATION. a. IS THIS AN INITIAL ENDORSEMENT? (X one) u

f. E-MAIL ADDRESS

(4) ZIP CODE(3) STATE(2) CITYe. ADDRESS. (1) STREET (Include apartment or suite number)

d. TELEPHONE (Include Area Code)c. SOCIAL SECURITY NUMBER (Last 4)b. TYPED OR PRINTED NAME (Last, First, Middle Initial)

(2) ENLISTED (1) OFFICER i. NUMBER OF MONTHS OF PRIOR ACTIVE MILITARY SERVICE PROSPECT HAS COMPLETED

j. SOURCE OF ORDINATION/PROFESSIONAL CREDENTIALS k. DATE OF ORDINATION/PROFESSIONAL CREDENTIALS (YYYYMMDD)

h. NUMBER OF YEARS OF PROFESSIONAL MINISTRY EXPERIENCE PROSPECT HAS COMPLETED

l. APPLICATION IS FOR (X one)

(1) CHAPLAIN CANDIDATE (4) ACTIVE DUTY (Navy Only: X (a) or (b)) (5) WITHDRAWAL OF ENDORSEMENT (a) Initial Active Duty - 3 Years(b) Extended Active Duty - Indefinite

(2) RESERVE(3) NATIONAL GUARD

(4) ZIP CODE(3) STATE(2) CITY

b. ADDRESS. (1) STREET (Include apartment or suite number)

(3) AIR FORCE(2) NAVY(1) ARMY

a. CHIEF OF CHAPLAINS (X appropriate block)

3. TO

h. WEB SITEg. E-MAIL ADDRESS

(4) ZIP CODE(3) STATE(2) CITYf. ADDRESS. (1) STREET (Include apartment or suite number)

e. FAX NUMBER (Include Area Code)d. TELEPHONE (Include Area Code)

c. EMPLOYER IDENTIFICATION NUMBER (IRC)

b. DATE OF CURRENT INTERNAL REVENUE CODE (IRC) 501(c)(3) EXEMPT STATUS

a. TYPED OR PRINTED NAME OF RELIGIOUS ORGANIZATION GRANTING RELIGIOUS MINISTRY PROFESSIONAL ENDORSEMENT

4. FROM (To be completed by Endorsing Agent)

5. COMMENTS

DD FORM 2088, DEC 2014 Adobe Designer 9.0PREVIOUS EDITION IS OBSOLETE.

Applicants Signature:________________________________________

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