Dd 1966 1 Form – Fill Out and Use This PDF

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 the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Directives Division, 4800 Mark Center Drive, Alexandria, VA 22350-3100 (0704-0173). 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.

SECTION II - EXAMINATION AND ENTRANCE DATA PROCESSING CODES

(FOR OFFICE USE ONLY - DO NOT WRITE IN THIS SECTION - Go on to Page 2, Question 20.)

16. APTITUDE TEST RESULTS

17. DEP ENLISTMENT DATA

18. ACCESSION DATA

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://dpclo.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/6156/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://dpclo.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 disclosure 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://dpclo.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/6156/a0601-270-usmepcom-dod.aspx) Army (http://dpclo.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/6131/a0600-8-104-ahrc.aspx) Navy (http://dpclo.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/6411/n01131-1.aspx; http://dpclo.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/6413/n01133-2.aspx)

Marine Corps (http://dpclo.defense.gov/Privacy/SORNsIndex/DODComponentArticleView/tabid/7489/Article/6777/m01133-3.aspx) Air Force (http://dpclo.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/5820/f036-aetc-r.aspx) Coast Guard (http://edocket.access.gpo.gov/2008/E8-29845.htm)

Official Military Personnel Files:

Army (http://dpclo.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/6128/a0600-8-104b-ahrc.aspx; http://dpclo.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/6129/a0600-8-104b-ngb.aspx)

Navy (http://dpclo.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/6405/n01070-3.aspx)

Marine Corps (http://dpclo.defense.gov/Privacy/SORNsIndex/DODComponentArticleView/tabid/7489/Article/6775/m01070-6.aspx) Air Force (http://dpclo.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/5876/f036-af-pc-c.aspx) Coast Guard (http://edocket.access.gpo.gov/2008/E8-29793.htm)

WARNING

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

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

INSTRUCTIONS

(Read carefully BEFORE filling out this form.)

1.Read Privacy Act Statement above before completing form.

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

3.Unless otherwise specified, write all dates as 8 digits (with no spaces or marks) in YYYYMMDD fashion. June 1, 2014 is written 20140601.

SECTION IV - CERTIFICATION

29.CERTIFICATION OF APPLICANT (Your signature in this block must be witnessed by your recruiter.)

a.I certify that the information given by me in this document is true, complete, and correct to the best of my knowledge and belief. I understand that I am being accepted for enlistment based on the information provided by me in this document; that if any of the information is knowingly false or incorrect, I could be tried in a civilian or military court and could receive a less than honorable discharge which could affect my future employment opportunities.

30.DATA VERIFICATION BY RECRUITER (Enter description of the actual documents used to verify the following items.)

31. CERTIFICATION OF WITNESS

a.I certify that I have witnessed the applicant's signature above and that I have verified the data in the documents required as prescribed by my directives. I further certify that I have not made any promises or guarantees other than those listed and signed by me. I understand my liability to trial by courts-martial under the Uniform Code of Military Justice should I effect or cause to be effected the enlistment of anyone known by me to be ineligible for enlistment.

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

(Use clear text English.)

33. CERTIFICATION OF RECRUITER OR ACCEPTOR

a.I certify that I have reviewed all information contained in this document and, to the best of my judgment and belief, the applicant fulfills all legal policy requirements for enlistment. I accept him/her for enlistment on behalf of the United States (Enter Branch of Service)

and certify that I have not made any promises or guarantees other than those listed in Item 32.a.

above. I further certify that service regulations governing such enlistments have been strictly complied with and any waivers required to effect applicant's enlistment have been secured and are attached to this document.

SECTION V - RECERTIFICATION

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

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

(Specify item(s) being continued by item number. Continue on separate pages if necessary.)

SECTION VII - STATEMENT OF NAME FOR OFFICIAL MILITARY RECORDS

37. NAME CHANGE.

If the preferred enlistment name (name given in Item 2) is not the same as on your birth certificate, and it has not been changed by legal procedure prescribed by state law, and it is the same as on your social security number card, complete the following:

c. I hereby state that I have not changed my name through any court or other legal procedure; that I prefer to use the name of

by which I am known in the community as a matter of convenience

and with no criminal intent. I further state that I am the same person as the person whose name is shown in Item 2.

USE THIS DD FORM 1966 PAGE ONLY IF EITHER SECTION APPLIES TO THE APPLICANT'S RECORD OF MILITARY PROCESSING.

SECTION VIII - PARENTAL/GUARDIAN CONSENT FOR ENLISTMENT

40.PARENT/GUARDIAN STATEMENT(S) (Line out portions not applicable)

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

has no other legal guardian other than me/us and I/we consent to his/her enlistment in the United States

(Enter Branch of Service)

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

b. FOR ENLISTMENT IN A RESERVE COMPONENT.

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