PUERTO RICO NATIONAL GUARD STATE COMMAND

REQUISITOS DE INGRESO EN LA GUARDIA ESTATAL DE PUERTO RICO - OFICIALES -

1. SOLICITUD DE INGRESO FORMA 104 O 102

2. FORMA 104-A (ENLISTED ONLY)

3. RESUME PERSONAL

4. DATA PERSONAL PARA EMERGENCIA FORMA 107

5. CERTIFICADO DE BUENA CONDUCTA

6. CERTIFICADO DE NACIMIENTO

7. CERTIFICADO DE LICENCIA, (COPIA) ENFERMEROS, DOCTORES, INGENIEROS, ETC.

8. SERVICIO PREVIO – SOMETA FORMA DD-214, NGB 22 Ó EQUIVALENTE.

9. EXAMEN MÉDICO – POR UN MÉDICO DE VETERANOS, GUARDIA NACIONAL O GUARDIA ESTATAL.

10. ANÁLISIS DE SANGRE, ORINA, ETC.

11. TIPO DE SANGRE

12. FORMA 2006

13. (1) FOTOGRAFÍA

14. ENTREVISTA POR EL COMANDANTE DE LA UNIDAD A INGRESAR Y TRAER PÁRRAFO Y LÍNEA

DE LA POSICIÓN DISPONIBLE PARA INGRESO.

15. CERTIFICACIÓN DE ASUME

16. PRUEBA DE DOPAJE

17. CERTIFICADO DE MATRIMONIO

18. 2 FOTOS 2X2 DE LA ESPOSA O ESPOSO

19. CERTIFICADO DE NACIMIENTO Y 2 FOTOS 2X2 PARA HIJOS DE 10 A 21 AÑOS DE EDAD/

20. ID CARD SE SEPARAN DE MARTES A JUEVES DE 10:00 AM – 11:30 AM Y DE 1:00 PM – 3 :00 PM

HEADQUARTERS PUERTO RICO STATE GUARD

Office of the Commander San Juan, Puerto Rico 00904

APPLICATION FOR RECOGNITION AND APPOINTMENT AS A COMMISSIONED OFFICER OR WARRANT OFFICER OF THE STATE GUARD OF PUERTO RICO.

Place:

FROM:

TO:

(city) (state)

Date:(day)

(Last Name) (First Name)

(House number and street)

(state) (Zip Code) (Home tel No.)

b. Business address:

c. Date and place of birth:

d. Are you a citizen of the United States by birth or naturalization?

(Number and street)

(state) (Zip Code)

Page-1

(Home tel No.)

Assistant Adjutant General for the State Guard of Puerto Rico

1.

I have read the PRSG Reg. 600-100, par 3 (Appointments) and par. 4 (Disqualifications) and understand it may take some time to process this application.

3. In connection with the application, I submit the following information, which I certify to be correct to the best of my knowledge:

a. Home address:

2.

Under the provisions of PRSG Regulation No. 600-100, I hereby apply for recognition and appointment as a member of Puerto Rico State Guard.

(Middle Name)

(month)

(Soc. Scty. No.)

(year)

e. Marital Status:

f. Number and relationship of Dependent:

g. Present occupation, years of experience, name and address of employer:

h. Experience in other lines and years of same:

i. Membership in professionals societies:

j. Decorations, citations, and commendations (attach copies):

k. Were you ever rejected for military service or appointment as a Commissioned or Warrant Officer? If yes, state when rejected and cause:

l. Have you ever been separated from the military by reason for classification, board action or court martial proceedings? If yes, give date, place and details:

(Single)

Puerto Rico State Guard - Officer Application Form - cont -

(Married) (Widowed) (Divorced)

m. Have you ever been arrested or convicted by a civil court for other than minor traffic violations? If yes, give date, place and details:

n. Have you ever been court martialed? If so, give date, place charge and final disposition:

Page-2

(Soc. Scty. No.)(Middle Name)(First Name)(Last Name)

o. School (1) Civilian

p. Record all Military Service: (1) Chronological statement of all active federal service:

q. Remark: (Any other information you may desire to submit)

r. Personal Resume: (Attach with this Form

s. Photographs: Include one (1) passport type photograph with form

t. Medical Exam: Forms STANDARD FORM 93 AND STANDARD FORM 88 enclosed.

u. Privacy Act Statement: DD FORM 2005 enclosed

v. Certificate of Good Conduct

Military service other than above (National Guard, Reserve, Cadet / Midshipman at military forces of a foreign country)* SUBMIT DD FORM 214 OR NGB 22 OR EQUIVALENT RECORD PRIOR SERVICE

(2) Military Service

(3) Other

Puerto Rico State Guard - Officer Application Form - cont -

Page-3

(Soc. Scty. No.)(Middle Name)

School Name

(Please indicate only highest school course degree)

(including Military Extension Courses)

(First Name)(Last Name)

Location Years Year Graduated Course or Degree

School Name Location Date Attended Course Graduated

From/To Station Grade Duty Assignment Unit

Puerto Rico State Guard - Officer Application Form - cont -

Page-4

(Soc. Scty. No.)(Middle Name)

Indorsement (prepared by receiving organization Commander)

INDORSEMENT (prepared by Group Commander)

(Signature of Commander)

The statements of the applicant have been verify by the undersigned and candidate desires to fill position of:

FROM:

TO:

Par. Line Unit

APPROVAL:

President Selection Board

(First Name)(Last Name)

LAST NAME

DATE OF INTERVIEW GRADE, NAME, ORG & TITLE OF COMMANDER SIGNATURE OF COMMANDER

APPLICANT HAS BEEN INTERVIEWED AND IS

OTHER BACKGROUND DATA

MEMBERSHIP IN YOUTH PROGRAMS

2.

UDERSTANDINGS

4. CARACTER AND SOCIAL ADJUSTMENT

3.

DECLARATIONS

Have you ever been enrolled in an ROTC, Junior ROTC or Sea Cadet Program, or have been a member of the Civil Air Patrol? Optional entry you may be entitled to a higher enlistment grade based on such membership and participation. If yes, enter organization and its address. On Back

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

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

c. Are you now drawing, or have any application pending, or approval for: Retired pay, disability allowance, severance pay, or a pension from the Government of the United States?

d. Are you a conscientious objector? That is, do you have, or have you ever had, a firm fixed, and sincere objection to participation in war in any form or to the bearing of arms because of religious training or belief?

e. Are you the only living child of your parents?

f. Have you ever been a draft evader or participate in an amnesty program?

g. Do you now have, or have you had within the past ten years, knowing membership with the specific intent of furthering the aims of, or adherence to, and active participation in any foreign or domestic organization or association or movement or group or combination of persons which unlawfully advocates or practices the commission os acts of force or violence to prevent others from exercising their rights under the Constitution of the United States or subdivision thereof by unlawful means? (If yes, give the name (s) of the organization (s) and inclusive dates of your membership) on back of form.

h. Have you ever visited a foreign country except as a member of the United States Armed Forces performing official duties? (If yes, give year and month, countries visited, and purpose of travel on back of form).

I UNDERSTAND THAT IF I AM REJECTED FOR ENLISTMENT BECAUSE OF A DESQUALIFICATION THAH I HAVE CONCEALED, I MAY NOT BE PROVIDED RETURN TRANSPORTATION FROM THE PLACE OF EXAMINATION TO MY HOME.

i. Have you ever worked for a foreign government? (If yes, give dates of employment, name of the government you worked for, and description and location of your duties, on back of form).

1. If you answer to every question is truthfully "NO", initial in the appropriate space. 2. You are not required to answer or explain your responses to these questions in writing if your answer is "YES" or you have reservations about answering questions of this nature. Instead, you may request a personal interview in which you may provide the required information for each question orally. a. If you choose the personal interview, the the information you give may be investigated; however any written record of the interview itself will not be retained more than six months after your entry on active duty and will not become a part of your permanent military personnel service record. b. This information may be requested from you again at some future date if you enlist and may become a part of your security investigative file at that time. This could occur as a result of your being considered for duties involving access to classified information or other types of duties requiring a personnel security investigation. 3. A "YES" answer will not necessarily disqualify you for enlistment; it will depend on the circumstances surrounding the situation involved.

INITIAL HERE IF YOU PREFER A PERSONAL INTERVIEW: ________________

DO NOT WRITE IN THIS BLOCK - TO BE COMPLETED BY: UNIT COMMANDER

1. NO

INITIALS

YES

SSAN

Page-5

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MEDICAL RECORD REPORT OF MEDICAL EXAMINATIONDATE OF EXAM

1. LAST NAME - FIRST NAME - MIDDLE NAME 2. IDENTIFICATION NUMBER 3. GRADE AND COMPONENT OR POSITION

4. HOME ADDRESS (Number, street or RFD, city or town, state and ZIP Code) 5. EMERGENCY CONTACT (Name and address of contact)

6. DATE OF BIRTH 7. AGE 8. SEX

FEMALE MALE

9. RELATIONSHIP OF CONTACT

10. PLACE OF BIRTH 11. RACE

WHITE BLACKAMERICAN INDIAN/ALASKA NATIVE

HISPANICWHITE

HISPANICBLACK

ASIAN/PACIFICISLANDER

12a. AGENCY 12b. ORGANIZATION UNIT 13. TOTAL YEARS GOVERNMENT SERVICE

a. MILITARY b. CIVILIAN

14. NAME OF EXAMINING FACILITY OR EXAMINER, AND ADDRESS 15. RATING OR SPECIALTY OF EXAMINER

16. PURPOSE OF EXAMINATION

17. CLINICAL EVALUATIONNOR-MAL

ABNOR-MAL(Check each item in appropriate column, enter "NE" if not evaluated.)

A. HEAD, FACE, NECK AND SCALP

B. EARS - GENERAL (INTERNAL CANALS) (Auditory acuity under items 39 and 40)

C. DRUMS (Perforation)

D. NOSE

E. SINUSES

F. MOUTH AND THROAT

G. EYES - GENERAL (Visual acuity and refraction under items 28, 29, and 36)

H. OPTHALMOSCOPIC

I. PUPILS (Equality and reaction)

J. OCULAR MOTILITY (Associated parallel movements nystagmus)

K. LUNGS AND CHEST

L. HEART (Thrust, size, rhythm, sounds)

M. VASCULAR SYSTEM (Varicosities, etc.)

N. ABDOMEN AND VISCERA (Include hernia)

O. PROSTATE (Over 40 or clinically indicated)

P. TESTICULAR

Q. ANUS AND RECTUM (Hemorrhoids, Fistulae) (Hemocult Results)

R. ENDOCRINE SYSTEM

S. G-U SYSTEM

T. UPPER EXTREMITIES (Strength, range of motion)

U. FEET

V. LOWER EXTREMITIES (Except feet) (Strength, range of motion)

W. SPINE, OTHER MUSCULOSKELETAL

X. IDENTIFYING BODY MARKS, SCARS, TATTOOS

Y. SKIN, LYMPHATICS

Z. NEUROLOGIC (Equilibrium tests under item 41)

AA. PSYCHIATRIC (Specify any personality deviation)

BB. BREASTS

CC. PELVIC (Females only)

NOR-MAL

ABNOR-MAL(Check each item in appropriate column, enter "NE" if not evaluated.)

NOTES: (Describe every abnormality in detail. Enter pertinent item number before each comment. Continue in item 42 and use additional sheets if necessary.)

18. DENTAL (Place appropriate symbols, shown in examples, above or below number of upper and lower teeth.) REMARKS AND ADDITIONAL DENTALDEFECTS AND DISEASES

RIGHT

LEFT

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1632 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

132

02

310

330

RestorableTeeth

132

/2

31/

330

MissingTeeth

132

X2

31X

330

Non-restorable

Teeth

X 132X

X2

31X

X 330X

Replacedby

Dentures

( 132(

X2

31X

) 330 )

FixedPartial

Dentures

19. TEST RESULTS (Copies of results are preferred as attachments)

A. URINALYSIS: (1) SPECIFIC GRAVITY

(2) URINE ALBUMIN

(3) URINE SUGAR

(4) MICROSCOPIC

B. CHEST X-RAY OR PPD (Place, date, film number and result)

C. SYPHILIS SEROLOGY (Specify test used and results)

D. EKG E. BLOOD TYPE AND RH FACTOR

F. OTHER TESTS

NSN 7540-00-634-403888-126Designed using Perform Pro, WHS/DIOR, Jan 97

STANDARD FORM 88 (Rev. 10-94) (EG)Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1

NO. OF SHEETS ATTACHEDNAME IDENTIFICATION NUMBER

MEASUREMENTS AND OTHER FINDINGS20. HEIGHT 21. WEIGHT 22. COLOR HAIR 23. COLOR EYES 24. BUILD

SLENDER MEDIUM HEAVY OBESE

25. TEMPERATURE

26. BLOOD PRESSURE (Arm at heart level) 27. PULSE (Arm at heart level)

A.SITTING

SYS.

DIAS.

B.RECUM-

BENT

SYS.

DIAS.

C.STANDING

(5 mins.)

SYS.

DIAS.

A. SITTING B. RECUMBENT C. STANDING (3 mins)

D. AFTER EXERCISE E. 2 MINS. AFTER

28. DISTANT VISION

RIGNT 20/

LEFT 20/

CORR. TO 20/

CORR. TO 20/

29. REFRACTION

BY

BY

S.

S.

CX

CX

30. NEAR VISION

CORR. TO

CORR. TO

BY

BY

31. HETEROPHORIA (Specify distance)

ESO EXO R.H. L.H. PRISM DIV. PRISM CONV. CT

PC PD

32. ACCOMMODATION

RIGHT LEFT

33. COLOR VISION (Test used and result) 34. DEPTH PERCEPTION (Test used and score)

UNCORRECTED

CORRECTED

35. FIELD OF VISION

RIGHT LEFT

36. NIGHT VISION (Test used and score) 37. RED LENS TEST 38. INTRAOCULAR TENSION

RIGHT LEFT

39. HEARING

RIGHT W/V /15SV /15

LEFT W/V /15SV /15

40. AUDIOMETER

RIGHT

LEFT

250256

500512

10001024

20002048

30002896

40004096

60006144

80008192

41. PSYCHOLOGICAL AND PSYCHOMOTOR (Tests used and score)

42. NOTES (Continued) AND SIGNIFICANT OR INTERVAL HISTORY

(Use additional sheets if necessary)

43. SUMMARY OF DEFECTS AND DIAGNOSES (List diagnoses with item numbers)

44. RECOMMENDATIONS - FURTHER SPECIALIST EXAMINATIONS INDICATED (Specify) 45A. PHYSICAL PROFILE

P U L H E S

45B. PHYSICAL CATEGORY

A B C

46. EXAMINEE (Check)

A. IS QUALIFIED FOR

B. IS NOT QUALIFIED FOR

47. IF NOT QUALIFIED, LIST DISQUALIFYING DEFECTS BY ITEM NUMBER

48. TYPED OR PRINTED NAME OF PHYSICIAN SIGNATURE

49. TYPED OR PRINTED NAME OF PHYSICIAN SIGNATURE

50. TYPED OR PRINTED NAME OF DENTIST OR PHYSICIAN (Indicate which) SIGNATURE

51. TYPED OR PRINTED NAME OF REVIEWING OFFICER OR APPROVING AUTHORITY SIGNATURE

STANDARD FORM 88 (Rev. 10-94) BACK

E

MEDICAL RECORD REPORT OF MEDICAL HISTORYDATE OF EXAM

NOTE: This information is for official and medically-confidential use only and will not be released to unauthorized persons

1. NAME OF PATIENT (Last, first, middle) 2. IDENTIFICATION NUMBER 3. GRADE

4a. HOME STREET ADDRESS (Street or RFD; City or Town; State; and ZIP Code) 5. EXAMINING FACILITY

6. PURPOSE OF EXAMINATION

NO. OF ATTACHED SHEETS:

STANDARD FORM 93 (REV. 6-96)Prescribed by ICMR/GSAFIRMR (41 CFR) 201-9.202-1

4b. CITY 4c. STATE 4d. ZIP CODE

d. HEIGHT e. WEIGHT

8. PATIENT'S OCCUPATION 9. ARE YOU (Check one)

RIGHT HANDED LEFT HANDED

10. PAST/CURRENT MEDICAL HISTORY

Arthritis, Rheumatism, orBursitis

Thyroid trouble or goiter

Eating disorder (anorexia bulimia, etc.)

c. ALLERGIES (Include insect bites/stings and common foods)

YES NODON'TKNOW

CHECK EACH ITEM

Scarlet fever

Rheumatic fever

Swollen or painful joints

Frequent or severe headaches

Dizziness or fainting spells

Eye trouble

Hearing loss

Suicide attempt or plans

Sleepwalking

Wear corrective lenses

Stutter or stammer

Wear a brace or back support

Lack vision in either eye

Wear a hearing aid

Eye surgery to correct vision

Household contact with anyonewith tuberculosis

Tuberculosis or positive TB test

Blood in sputum or whencoughing

Excessive bleeding after injury ordental work

Recurrent ear infections

Chronic or frequent colds

Severe tooth or gum trouble

Sinusitis

Hay fever or allergic rhinitis

Head injury

YES NODON'TKNOW

CHECK EACH ITEM

Kidney stone or blood in urine

Sugar or albumin in urine

Sexually transmitted diseases

Recent gain or loss of weight

Jaundice or hepatitis

Broken bones

Adverse reaction to medication

Tumor, growth, cyst, cancer

Hernia

Hemorrhoids or rectal disease

Frequent or painful urination

Bed wetting since age 12

Shortness of breath

Pain or pressure in chest

Chronic cough

Palpitation or pounding heart

Heart trouble

High or low blood pressure

Cramps in your legs

Frequent indigestion

Gall bladder trouble orgallstones

Asthma

CHECK EACH ITEM

Asbestos or toxic chemicalexposure

Plate, pin or rod in any bone

Easy fatigability

Been told to cut down orcriticized for alcohol use

Used illegal substances

Used tobacco

"Trick" or locked knee

Loss of finger or toe

Painful or "trick" shoulderor elbow

Recurrent back pain or anyback injury

Foot trouble

Nerve Injury

Paralysis (including infantile)

Epilepsy or seizure

Car, train, sea or air sickness

Frequent trouble sleeping

Depression or excessive worry

Loss of memory or amnesia

Nervous trouble of any sort

Periods of unconsciousness

Parent/sibling with diabetes,cancer, stroke or heart disease

X-ray or other radiation therapy

Chemotherapy

YES NODON'TKNOW

Stomach, liver or intestinal trouble

Skin diseases

Bone, joint or other deformity

NSN 7540-00-181-8368Previous edition not usable

7. STATEMENT OF PATIENT'S PRESENT HEALTH AND MEDICATIONS CURRENTLY USED (Use additional pages if necessary)

a. PRESENT HEALTH b. CURRENT MEDICATION REGULAR OR INTERM.

25. PHYSICIAN'S SUMMARY AND ELABORATION OF ALL PERTINENT DATA (Physician shall comment on all positive answers in Items 7 through 11. Physician may

develop by interview any additional medical history deemed important, and record any significiant findings here.)

26c. DATE26a. TYPED OR PRINTED NAME OF PHYSICIAN OR EXAMINER 26b. SIGNATURE

STANDARD FORM 93 (REV. 6-96) BACK

12. Have you been refused employment or been unable to hold a job orstay in school because of:

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

b.Inability to perform certain motions.

c. Inability to assume certain positions.

d.Other medical reasons (If yes, give reasons.)

13. Have you ever been treated for a mental condition? (If yes, specifywhen, where, and give details.)

14. Have you ever been denied life insurance? (If yes, state reason andgive details.)

15. Have you had, or have you been advised to have, any operation. (If yes, describe and give age at which occurred.)

16. Have you ever been a patient in any type of hospital? (If yes,specify when, where, why, and name of doctor and complete addressof hospital.)

17. Have you consulted or been treated by clinics, physicians, healers, or other practitioners within the past 5 years for other than minor illnesses? (If yes, give complete address of doctor, hospital, clinic, anddetails.)

18. Have you ever been rejected for military service because ofphysical, mental, or other reasons? (If yes, give date and reason forrejection.)

19. Have you ever been discharged from military service because ofphysical, mental, or other reasons? (If yes, give date, reason, and type of discharge; whether honorable, other than honorable, forunfitness or unsuitability.)

20. Have you ever received, is there pending, or have you ever applied for pension or compensation for existing disability? (If yes, specify what kind, granted by whom, and what amount, when, why.)

21. Have you ever been arrested or convicted of a crime, other thanminor traffic violations. (If yes, provide details.)

22. Have you ever been diagnosed with a learning disability? (If yes,give type, where, and how diagnosed.)

I certify that I have reviewed the foregoing information supplied by me and that it is true and complete to the best of my knowledge. I authorize any of the doctors, hospitals,or clinics mentioned above to furnish the Government a complete transcript of my medical record for purposes of processing my application for this employment or service. Iunderstand that falsification of information on Government forms is punishable by fine and/or imprisonment.

24c. DATE24a. TYPED OR PRINTED NAME OF EXAMINEE 24b. SIGNATURE

NOTE: HAND TO THE DOCTOR OR NURSE, OR IF MAILED MARK ENVELOPE "TO BE OPENED BY MEDICAL OFFICER ONLY".

23. LIST ALL IMMUNIZATIONS RECEIVED

11. FEMALES ONLY

CHECK EACH ITEM

Treated for a female disorder

Change in menstrual pattern

DATE OF LAST MENSTRUAL

PERIOD

DATE OF LAST PAP SMEAR DATE OF LAST MAMMO-

GRAMYES NODON'TKNOW

CHECK EACH ITEM. IF "YES" EXPLAIN IN BLANK SPACE TO RIGHT. LIST EXPLANATION BY ITEM NUMBER.

YES NOITEM