Ngb 34 1 Form – Fill Out and Use

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APPLICATION FOR ACTIVE GUARD/RESERVE (AGR) POSITION

The proponent agency is ARNG-HRH. The prescribing directive is NGR (AR) 600-5 / ANGI 36-101

PRIVACY ACT STATEMENT

AUTHORITY: Title 32 USC 502(f), AR 135-18, NGR (AR) 600-5, ANGI 36-101.

PRINCIPAL PURPOSE: To provide information for use in determining eligibility/qualifications for Active Guard/Reserve (AGR) positions. A copy will be provided to the applicant. The original will be maintained by the human resources office for state records. For organizational use only.

ROUTINE USES: None.

DISCLOSURE: Voluntary; however, if not provided you will not be considered for the AGR program.

POSITION ANNOUNCEMENT #:			POSITION TITLE:
NAME: (Last, First, Middle)						DATE OF BIRTH: (yyyymmdd))
CURRENT HOME ADDRESS:		(Street, City, State, Zip Code)				HOME PHONE:
						OFFICE PHONE:
(Enlisted)	DATE OF ENLISTMENT:			GRADE:	MOS/SSI/AFSC:	ETS DATE:
(Officer/WO)	DATE OF FEDERAL RECOGNITION:			GRADE:	BRANCH:	MRD DATE:
SECURITY CLEARANCE:

SECTION I - EDUCATION AND SPECIAL QUALIFICATIONS

1.COLLEGE OR UNIVERSITY: (Officer Applicants - Accredited Colleges only)

Name, City & State	Date From	Date To	Degree Program	Credit Hours Quarter/Semester

Chief Undergraduate Subject:

Chief Graduate Subject:

2.OTHER SCHOOLS OR TRAINING: (Vocational, Trade or Business)

Name, City & State	Date From	Date To	Course Title	Hours Completed

3.SKILLS AND QUALIFICATIONS: Special skills and qualifications with office machines (Word Processing - WPM), wheel and track vehicles, etc. Also list any licenses or certificates held (Pilot, Nurse).

SECTION II - EMPLOYMENT HISTORY

May we contact your present employer regarding your character, qualification, and record of employment?					CHECK ONE:		YES	NO
(A "NO" answer will not affect your consideration for employment.)
1. NAME AND ADDRESS OF EMPLOYER:		DATES EMPLOYED				AVERAGE HRS. PER WEEK
		FROM	TO
TITLE OF POSITION:	IMMEDIATE SUPERVISOR	& PHONE NUMBER:		NUMBER OF		EMPLOYEES YOU SUPERVISED:
TYPE OF BUSINESS:	YOUR REASON FOR LEAVING:

DESCRIPTION OF WORK: (Describe your specific responsibilities and accomplishments)

NGB Form 34-1, 20131111

(PREVIOUS EDITONS ARE OBSOLETE.)

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	SECTION II - EMPLOYMENT HISTORY (Continued)
OTHER EMPLOYMENT
May we contact WKLV employer regarding your character, qualification, and record of employment?					CHECK ONE:		YES	NO
(A "NO" answer will not affect your consideration for employment.)
. NAME AND ADDRESS OF EMPLOYER:		DATES EMPLOYED					AVERAGE HRS. PER WEEK
		FROM		TO
TITLE OF POSITION:	IMMEDIATE SUPERVISOR	& PHONE NUMBER:			NUMBER OF	EMPLOYEES YOU SUPERVISED:
TYPE OF BUSINESS:	YOUR REASON FOR LEAVING:

DESCRIPTION OF WORK: (Describe your specific responsibilities and accomplishments)

S

SECTION III - MILITARY HISTORY

1.MILITARY SERVICE:(Start with most recent service and show changes in grade and duty in reverse chronological order.)

FROM	TO	AC	ARNG/ANG	RC	GRADE	ORGANIZATION	DUTY

2. MILITARY TRAINING:

FORMAL MILITARY SCHOOLING COMPLETED

	COURSE TITLE AND NUMBER	DURATION OF COURSE		CORRESPONDENCE COURSES
		WEEKS	DAYS	COURSE/SUBCOURSE TITLE	COURSE HOURS

3.MILITARY QUALIFICATIONS (List any primary MOS/SSI which has been awarded on orders.)

MOS/SSI/AFSC

DATE AWARDED INDICATE HOW QUALIFICATIONS WERE OBTAINED (Service School, On the Job Training, Civilian Experience, etc.)

4. INDICATE ANY ON THE JOB TRAINING WHICH IS QUALIFYING FOR AN MOS/SSI WHICH HAS NOT YET BEEN AWARDED ON ORDERS.

DUTY MOS/SSI/AFSC	EXACT TITLE OF POSITION	FROM	TO

NGB Form 34-1, 20131111

(PREVIOUS EDITONS ARE OBSOLETE.)

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SECTION IV - PERSONAL BACKGROUND QUESTIONAIRE

(All Applicants Must Complete) Utilize the Continuation/Remarks section to fully explain any "YES" answers (except 9 & 10). YES NO Attach a seperate sheet of paper if more space is necessary.

1. Within the last five years, have you been fired for any reason?

2. Within the last five years, have you quit a job after being notified that you would be fired?

3. Have you ever been convicted, forfeited collateral, or now under charges for any felony or firearms or explosives offense against the law?

4.During the past seven years, have you been convicted, imprisoned, on probation or parole, or forfeited collateral or are you now under charges for any offense against the law not included in Question 3?

5. While in the military, have you ever been convicted by a General Court Martial?

6. Does the United States Government employ, in a civilian capacity or as a member of the Armed Forces, any relative of yours by blood or marriage?

7.Do you receive or are you entitled to receive federal, military retired or retainer pay, service annuities, or other compensation based upon military, federal, civilian service, or eligible for immediate federal civil service?

8. Have you ever been removed from military service due to unsuitability?

9.Will you be able to complete a minimum of 5 years of continuous AGR Service prior to completing 18 years of Active Federal Service or your Mandatory Removal Date (MRD)?

10.Are you a candidate for an elected office, holding a civil office (full or part-time) or engaged in partisan political activities as defined in

AR 600-20/ANGI 36-101/DoD Directive 1344.10, Political Activities by Members of the Armed Forces on Active Duty?

11.Have you been involuntarily removed from unit (Selected Reserve) service based on maximum years of service, qualitative retention or selective retention board action?

12.Have you been involuntarily removed from unit (Selected Reserve) service for cause or been relieved for cause from any duty assignment, including but not limited to relief from command in the past year?

13. Do you currently possess or is a report of suspension of favorable actions pending?

14. Have you voluntarily separated from the AGR Program in any state for one or more days within the past year? (ARNG Applicants Only) 15. Have you been voluntarily separated from the AGR Program or voluntarily separated in lieu of adverse action?

16.(OFFICERS AND WARRANT OFFICERS ONLY.) Have you been non-selected for promotion as not best qualified for promotion board convened by Headquarters, or Department of the Army Headquarters, within the past 12 months?

17. Have you met the minimum requirement for each fitness component by scoring an overall score of 75 points or higher, per AFI 36-2905.

SECTION V - CONTINUATION/REMARKS

Use the Continuation/Remarks section to fully explain any "YES" answers (except 9 & 10). Attach a seperate sheet of paper if more space is necessary.

SECTION VI - CERTIFICATIONS AND AUTHORITY FOR RELEASE INFORMATION

I have completed this application with the knowledge and understanding that any or all items contained herein may be subject to investigation. I consent to the release of information concerning my capacity and fitness by employer, educational institution, law enforcement agencies, and other individuals and agencies to personnel specialists for purpose of employment. I also understand that a false answer to any question in this application may be grounds for not being employed, or for being released after I begin work.

NGB Form 34-1, 20131111

(PREVIOUS EDITONS ARE OBSOLETE.)

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