Da Form 4711 – Fill Out and Use This PDF

STATEMENT OF LAW VIOLATIONS

For use of this form, see AR 601-270; the proponent agency is DCS, G-1.

DATA REQUIRED BY THE PRIVACY ACT OF 1974

AUTHORITY: Military Selective Service Act - 50 USC Appendix 451, and sections following; and Executive Order 9397, 22 November 1943.

PRINCIPAL PURPOSE: Determine moral qualifications of selective service registrants for introduction into the Armed Forces of the United States.

ROUTINE USES: This information is maintained and used in strict confidence in accordance with federal law and regulations. The information may be submitted for verification by appropriate law enforcement or court officials. Records of civil convic- tion or adverse juvenile adjudication are processed for review in order that qualifications for military service may be determined in accordance with standards prescribed by the Department of Defense.

DISCLOSURE: Disclosure of requested information is mandatory, except your social security number, disclosure of which is voluntary.

Your answers to the following questions will be verified with the Federal Bureau of Investigation (FBI), and other agencies to determine any previous records of arrest or convictions or juvenile court adjudications. If you conceal such records at this time you may upon induction be subject to disciplinary action under the uniform code of military justice and or discharge from the military service with other than an honorable discharge.

QUESTION

NO

YES

a. Have you ever been arrested, charged, cited, or held by Federal, State, or other law enforcement or juvenile authorities regardless of whether the citation or charge was dropped or dismissed or you were found not guilty?

b. As a result of being arrested, charged, cited, or held by law enforcement or juvenile authorities, have you ever been convicted, fined by or forfeited bond to a Federal, State, or other judicial authority or adjudicated a youth- ful offender or juvenile delinquent (regardless of whether the record in your case has been "sealed" or otherwise stricken from the court record)?

c. Have you ever been detained, held in, or served time in any jail or prison, or reform or industrial school or any juvenile facility or institution under the jurisdiction of any City, County, State, Federal or foreign country?

d. Have you ever been awarded, or are you now under suspended sentence, parole, or probation or awaiting any action on charges against you?

e. Have you been released from parole, probation, juvenile supervision, or given a suspended sentence or relieved of charges pending on condition that you apply for entry in the US Armed Forces?

f. Are you now involved in a party to or connected with any court action or civil suit? (Explain "yes" answer in

remarks section below).

Explain below "yes" answers in "a" through "e".

Be careful to include ALL incidents with law enforcement authorities.

REMARKS (Continue on reverse, if necessary)

CERTIFICATION

I understand that if information provided by me in this document is knowingly false or incorrect, I may be prosecuted under Federal civilian or military law or subject to administrative separation proceedings and, in either instance, I may receive a less than Honorable Discharge. I certify that the information given by me in this document is true, complete, and correct to the best of my knowledge and belief.