Us Army Application Form PDF Details

The US Army Application Form, officially known as DA Form 61, is a detailed document designed for individuals seeking to obtain an appointment as a commissioned or warrant officer in the Regular Army, Army Reserve, or selection to attend the US Army Officer Candidate School. It serves a critical function in the military's personnel recruitment and management, dictated by various regulations such as AR 135-100, AR 145-1, AR 351-5, and AR 601-100, with the DCSPER acting as the proponent agency. The form's sections cover a wide range of information necessary for determining an applicant's qualifications and suitability for the desired role. This includes personal data, education background, any military history, and specific preferences for service branches and specialties. Applicants must also disclose any past legal issues or affiliations with foreign governments, which are crucial for evaluating trustworthiness and commitment to the United States. Moreover, DA Form 61 requires candidates to express their understanding and willingness to accept assignments as deemed in the best interest of the service, highlighting the importance of flexibility and dedication in military roles. By collecting comprehensive background information, the US Army ensures that only the most qualified individuals are considered for positions that match their skills and aspirations, while also fulfilling the Army's operational requirements.

QuestionAnswer
Form NameUs Army Application Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesus army recruitment form, us army application form 2020, us army form online registration, u s army form

Form Preview Example

APPLICATION FOR APPOINTMENT

For use of this form, see AR 135-100, AR 145-1, AR 351-5, and AR 601-100; the proponent agency is DCSPER

DATA REQUIRED BY THE PRIVACY ACT OF 1974

AUTHORITY:

PRINCIPAL PURPOSE:

ROUTINE USES:

DISCLOSURE

Title 10 United States Code, Section 3012 (Title 5 United States Code, Section 552a)

To obtain an appointment as a commissioned or warrant officer in the Regular Army or Army Reserve, or to obtain selection to attend the US Army Officer Candidate School.

Basis for determination of qualifications and background information for eligibility for consideration for appointment as a Regular Army or Army Reserve commissioned/warrant officer or for selection for attendance at the US Army Officer Candidate School.

Disclosure of information requested in DA Form 61 is voluntary. Failure to provide the required information will result in non-acceptability of the application.

 

 

1. TYPE OF APPOINTMENT FOR WHICH APPLICATION IS SUBMITTED

 

 

2.

GOVERNING REGULATION OR CIRCULAR

(Specify appropriate section(s) if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMMISSIONED OFFICER - REGULAR ARMY

 

 

 

 

 

 

 

 

 

3.

GRADE FOR WHICH APPLYING (Reserve appointments only)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMMISSIONED OFFICER - ARMY RESERVE

 

 

 

 

 

 

 

 

 

 

4. SOURCE OF APPLICATION (ROTC only)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WARRANT OFFICER - REGULAR ARMY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DMG

DATE DESIGNATED:

 

 

 

 

 

 

 

 

 

 

WARRANT OFFICER - ARMY RESERVE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SCHOLARSHIP - ENTER 1, 2, 3 OR 4 YEARS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OFFICER CANDIDATE SCHOOL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. ONLY FOR APPLICANTS FOR APPOINTMENT AS WARRANT OFFICERS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(List choice by MOS code and title)

 

 

 

 

 

 

 

6. BRANCH AND SPECIALTY PREFERENCES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Regular Army and Officer Candidate applicants and all ROTC graduates:

 

 

 

 

 

 

 

 

a. MOS CODE

 

 

 

 

 

b. MOS TITLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

In numerical sequence, indicate 10 branch preferences other than CA and SS.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

USAR applicants: If applying for a specific Reserve vacancy, indicate

ONLY the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

branch of the vacant position; all other applicants may enter more than one branch.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PERSONAL DATA

 

 

 

 

 

 

 

 

 

 

PREFER-

 

 

7. NAME

(Last, first, middle)(Explain variations from birth certificate in Item 41)

 

8. GRADE

9a. SOCIAL SECURITY NUMBER

 

BRANCH

SPECIALTY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ENCE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. BRANCH

 

11. TOTAL YRS

 

12. MARITAL

 

 

13. NUMBER OF DEPENDENTS UNDER 18

9b. SELECTIVE SERVICE NUMBER

 

 

 

 

 

 

(MOS if enl or wo)

 

ACTIVE SERVICE

 

STATUS

 

 

YEARS OF AGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AG

 

14. DATE OF

 

15. PLACE OF BIRTH (City, county,

 

16. SEX

 

17. COMPLETE MILITARY ADDRESS

(If presently on active duty) (Include ZIP Code)

 

 

 

 

 

 

BIRTH

 

 

 

 

 

state)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AV

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHONE AND/OR DSN NUMBER

 

 

 

 

 

 

 

 

 

 

CA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CM

 

18. PERMANENT ADDRESS

(Include ZIP Code)

 

 

 

 

 

 

 

 

 

19. CURRENT MAILING ADDRESS

(If difference from Item 18) (Include ZIP Code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHONE

(Include area code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHONE (Include area code)

 

 

 

 

 

 

 

 

 

 

FI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IN

 

20. US

 

a. NATIVE

 

b.

 

 

 

NATURALIZATION

 

c. APPLICANT'S CERTIFICATE NO. (If Item b. checked) (Date, place, court)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITIZEN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

 

 

YES

 

 

 

 

 

 

 

DERIVED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

NO

 

 

 

 

 

IMMIGRANT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QM

 

21. CIVILIAN EDUCATION (See page 3 for additional requirements for professional personnel)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SC

 

a. HIGH SCHOOL GRADUATE

 

 

 

 

b. NAME AND LOCATION OF HIGH SCHOOL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TC

 

 

 

 

c. NAME AND LOCATION OF EACH COLLEGE

 

 

 

 

 

 

 

 

(2)

 

(3)

(4)

 

 

 

 

(5)

 

 

 

 

 

 

 

 

 

 

(1)

 

 

SEMESTER

DATE GRADUATED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AN

 

 

 

 

OR UNIVERSITY ATTENDED

(Include USMA,

 

 

 

YEARS

OR WILL GRADUATE

 

MAJOR

 

 

 

 

 

 

 

 

 

DEGREE

 

CREDITS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

USNA, USAFA, USCGA, and USMMA)

 

 

ATTENDED

 

 

 

 

 

 

 

 

SUBJECT

 

 

 

 

CH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EARNED

DAY

MONTH

 

YEAR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

JA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SP

 

d. SPECIAL EDUCATIONAL HONORS, SCHOLAR-

e. IF YOU HAVE EVER BEEN EXPELLED FROM SCHOOL, OR PLACED ON PROBATION, EITHER FOR

 

 

 

 

 

SHIPS, ETC.

 

 

 

 

 

 

 

 

 

 

 

 

 

ACADEMIC OR DISCIPLINARY REASONS, EXPLAIN (Continue in Item 41(Remarks))

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22.HIGHEST LEVEL SERVICE SCHOOL ATTENDED

a. NAME OF SCHOOL

b. COURSE

c. DATES

(Mo-Yr)

 

COMPLETED

d. IF NOT COMPLETED GIVE REASON

 

 

 

 

 

 

 

 

 

 

 

FROM

TO

YES

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

23a. FOREIGN LANGUAGES AND DEGREE OF PROFICIENCY

 

 

 

 

 

 

 

 

 

b. ALAT SCORE (If applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DA FORM 61, JUN 1981

EDITION OF 1 AUG 74 AND DA FORM 61-R, 26 SEP 75, PRIVACY ACT STATEMENT, ARE OBSOLETE.

 

 

 

 

 

 

 

 

 

 

 

 

 

APD LC v2.01ES

24. ARE YOU NOW, OR HAVE YOU EVER BEEN A CONSCIENTIOUS OBJECTOR?

 

YES

 

NO (If yes, attach affidavit)

25.

I UNDERSTAND THAT, IF I AM SELECTED FOR APPOINTMENT, I WILL BE EXPECTED TO ACCEPT SUCH ASSIGNMENTS AS ARE IN THE BEST INTEREST OF THE SERVICE REGARDLESS OF MY MARITAL STATUS AND/OR RESPONSIBILITY FOR DEPENDENTS; AND IT IS MY RESPONSIBILITY TO MAKE APPROPRIATE ARRANGEMENTS FOR THE CARE OF MY DEPENDENTS SHOULD I BE REQUIRED TO PERFORM DUTY IN AN AREA WHERE DEPENDENTS ARE NOT PERMITTED.

26.HAVE YOU EVER UNDER EITHER MILITARY OR CIVILIAN LAW BEEN INDICTED OR SUMMONED IN TO COURT AS A DEFENDANT IN A CRIMINAL PROCEEDING (Including any proceedings involving juvenile offenses, article 15, UCMJ, and any court-martial) REGARDLESS OF THE RESULT OF TRIAL, OR CONVICTED, FINED, IMPRISONED, PLACED ON PROBATION, PAROLED OR PARDONED, OR HAVE YOU EVER BEEN ORDERED TO DEPOSIT BAIL OR COLLATERAL FOR THE VIOLATION OF ANY LAW, POLICE REGULATION OR ORDINANCE? (Exclude traffic violations involving a fine or forfeiture of $100 or less).

YES

NO IF YES, ATTACH REQUEST FOR WAIVER LISTING THE DATE, THE NATURE OF EACH ALLEGED OFFENSE OR VIOLATION, THE NAME AND LOCATION OF

THE COURT OR PLACE OF HEARING, AND THE PENALTY IMPOSED OR OTHER DISPOSITION OF EACH CASE AND FURNISH COPY OF COURT ACTION OR DETAILED STATEMENT IN AFFIDAVIT FORM AS TO THE OUTCOME OF EACH CASE.

27.ACTIVE MILITARY SERVICE (Indicate tour with each organization separately - show ROTC Camps in Item 39)

a. ORGANIZATION

b. DATES (Day, Month, Year)

c. BRANCH/MOS

d. PRIOR

e. HIGHEST GRADE

(US Armed Forces, USCG, NOAA,

 

 

(As appropriate)

SERVICE NO.

AND COMPONENT

FROM

TO

US Public Health Service, Peace Corps)

(If applicable)

 

ENLISTED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WARRANT OFFICER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMMIS- SIONED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

f. DATE CURRENT ACTIVE DUTY TOUR TERMINATES

 

g. DATE OF LAST ADL PROMOTION

 

 

28.RESERVE OR NATIONAL GUARD SERVICE (Not on active duty)

a. ORGANIZATION

b. DATES (Day, Month, Year)

c. BRANCH/MOS

d. PRIOR

e. HIGHEST GRADE

(US Armed Forces, USCG, NOAA,

 

 

(As appropriate)

SERVICE NO.

AND COMPONENT

FROM

TO

US Public Health Service, Peace Corps)

(If applicable)

 

ENLISTED

 

 

 

 

 

 

 

WARRANT

OFFICER

 

 

 

 

 

 

 

COMMIS-

SIONED

 

 

 

 

 

 

 

29. SOURCE OF CURRENT COMMISSION (If applicable)

 

 

 

 

 

OTHER

 

 

 

 

 

ARNGUS:

 

OCS

 

 

DIRECT APPOINTMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

USAR:

 

 

ROTC

 

 

 

ROTC (ECP)

 

ROTC (SMP)

 

OCS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DIRECT APPOINTMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

30.AWARDS (Do not list theater or service medals)

31.

HAVE YOU EVER APPLIED AND NOT BEEN SELECTED FOR: a. ROTC

 

 

 

YES

 

 

 

 

NO

b. OCS

 

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. APPOINTMENT IN RESERVE COMPONENT (USAR/ARNG)

 

 

YES

 

NO

 

 

d. APPOINTMENT IN REGULAR ARMY

 

 

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AS A WARRANT OFFICER

 

 

 

 

 

 

 

 

 

 

AS A WARRANT OFFICER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AS A COMMISSIONED OFFICER

 

 

 

 

 

 

 

 

 

 

AS A COMMISSIONED OFFICER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e. IF ANSWER IS "YES", EXPLAIN FULLY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

32.

ARE YOU NOW OR HAVE YOU EVER BEEN IN THE MILITARY SERVICE OF OR BEEN EMPLOYED BY A FOREIGN GOVERNMENT

(If yes, give dates, country and type of service or

 

 

 

employment)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

33.

HAVE YOU EVER RESIGNED OR BEEN ASKED TO RESIGN IN LIEU OF ELIMINATION PROCEEDINGS; BEEN DISCHARGED IN LIEU OF ELIMINATION, FURLOUGHED

 

(other than

 

 

 

regular furlough or leave), OR PLACED ON INACTIVE STATUS WHILE SERVING IN THE US ARMED FORCES; OR, HAVE YOU EVER RESIGNED OR BEEN ASKED TO RESIGN FROM

 

 

 

A POSITION WHILE IN PRIVATE OR GOVERNMENT EMPLOYMENT? (If yes, state circumstances; if more space is required, continue on separate sheet).

 

 

 

 

 

 

 

 

 

 

YES

NO

APD LC v2.01ES

34. APPLICANTS FOR JUDGE ADVOCATE GENERAL'S CORPS ONLY

35. APPLICANTS FOR

 

CHAPLAINS BRANCH ONLY

 

 

 

 

 

 

BARS OF WHICH YOU ARE A MEMBER (Specify dates)

RELIGIOUS DENOMINATION BY

 

 

WHICH YOU WILL BE ENDORSED

 

 

 

 

36.APPLICANTS FOR MEDICAL AND DENTAL CORPS ONLY

a. TRAINING

 

b. NAME AND LOCATION OF HOSPITAL

c. DATES (Month and Year)

 

 

 

 

 

 

LEVEL

 

TYPE

FROM

 

TO

 

 

 

 

 

 

 

 

 

 

INTERNSHIP

 

 

 

 

 

 

RESIDENCY TNG

 

 

 

 

 

 

 

 

 

 

 

 

 

SPECIALTY TNG

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d. SPECIALTY BOARDS

e. DATES OF CERTIFICATION

(Day, Month, Yr)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

f. PLACE IN WHICH CURRENTLY LICENSED

37.APPLICANTS FOR ARMY NURSE CORPS AND ARMY MEDICAL SPECIALIST CORPS ONLY

a. NAME OF NURSING OR ACCREDITED PROFESSIONAL SCHOOL

b. LOCATION

 

 

 

 

 

 

 

c. DATES OF ATTENDANCE (Mo, Yr)

d. STATE AND CURRENT REGISTRATION NUMBER

 

e.

STATE AND DATE OF INITIAL

 

 

 

 

 

 

REGISTRATION (Day, Month, Year)

FROM

TO

 

 

 

 

 

 

 

 

 

 

 

 

f.POSTGRADUATE COURSES (Include courses at general hospitals, service schools, and short courses)

(1)

(2)

(3)

SEMESTER

DATES OF ATTENDANCE

(Month, Year)

SUBJECT OR COURSE

NAME AND LOCATION OF SCHOOL OR HOSPITAL

 

CREDITS

 

 

 

 

 

 

EARNED

FROM

 

TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

38. HAVE YOU BEEN EMPLOYED BY THE US ARMY AS A DIETITIAN, OCCUPATIONAL OR PHYSICAL THERAPIST?

(If yes, give dates)

YES

NO

 

39.ARMY ROTC (To be completed only by prospective ROTC graduates applying for appointment in USAR or RA)

SUCCESSFULLY COMPLETED AROTC PROGRAM AS FOLLOWS

COURSE

DATES ATTENDED

(Month and Year)

 

 

c. CAMP TRAINING

 

 

 

 

 

 

 

FROM

TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. BASIC

 

(1)

INSTALLATION

(Basic)

COMPLETION DATE

(Month, Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(2)

INSTALLATION

(Advanced/Ranger)

COMPLETION DATE

(Month, Year)

b.ADVANCED

40.MAIN CIVILIAN EMPLOYMENT

a. NAME AND ADDRESS OF EMPLOYER

b. JOB TITLE

 

c. MONTH AND YEAR

 

 

 

 

 

 

 

FROM

 

TO

 

 

 

 

 

b. PRINCIPAL DUTIES (Describe briefly)

41.REMARKS (Experience, proficiencies and special abilities not shown elsewhere in this application. Those required to enter primary entry specialties, see Para 1-27d,e, AR 601-100). (If more space is required, attach additional sheet)

DATE

SIGNATURE OF APPLICANT

42.THE INFORMATION CONTAINED HEREIN IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.

APD LC v2.01ES

THIS PAGE NOT TO BE COMPLETED BY APPLICANT

PART I - RECOMMENDATION FOR APPOINTMENT OF ROTC GRADUATE AS A (REGULAR) OR

(RESERVE) COMMISSIONED OFFICER OF THE ARMY (AR 601-100, AR 145-1) (To be completed by PMS only)

FROM: (Name and Address of Institution)

TO: (Appropriate Region Commander)

 

 

a. APPLICANT WILL HAVE SUCCESSFULLY COMPLETED AT THIS INSTITUTION THE PRESCRIBED COURSE FOR THE UNIT ON

 

 

b. APPLICANT

HAS

HAS NOT COMPLETED SUCCESSFULLY THE REQUIRED CAMP TRAINING.

 

(Date)

 

 

c. APPLICANT

WILL HAVE ATTAINED

WILL NOT HAVE ATTAINED, A BACCALAUREATE DEGREE UPON SUCCESSFUL COMPLETION OF THE ROTC COURSE.

d. I CONSIDER APPLICANT PHYSICALLY, MENTALLY, MORALLY, AND PROFESSIONALLY QUALIFIED FOR APPOINTMENT AS A

REGULAR

RESERVE COMMISSIONED

OFFICER OF THE ARMY RECOMMEND HIS APPOINTMENT.

 

 

e.APPLICANT WILL ATTAIN FULL QUALIFICATION FOR, AND SHOULD BE APPOINTED ON

(Day, Month and Year)

DATE

BRANCH FOR ASSIGNMENT

SIGNATURE AND GRADE (PMS)

PART II - RECOMMENDATION FOR APPLICANTS FOR OCS ONLY (AR 351-5)

a. STATEMENT

TO:

 

 

 

 

 

 

DATE

 

 

 

 

 

 

 

 

 

1. I HAVE KNOWN THE APPLICANT FOR

 

MONTHS. HE HAS SERVED UNDER ME FOR

 

MONTHS. HIS PRINCIPAL DUTY IS

 

 

 

 

 

 

 

 

 

 

 

 

2. I

DO

DO NOT RECOMMEND THE APPLICANT.

 

 

 

 

 

3.REMARKS (Include your opinion as to his/her overall ability (to include leadership) and value to the service).

ENCLOSURES

ORGANIZATION

SIGNATURE

TYPED NAME, GRADE AND TITLE

b.STATEMENT TO:

DATE

1.

I HAVE KNOWN THE APPLICANT FOR

 

MONTHS. HE HAS SERVED UNDER ME FOR

 

MONTHS. HIS PRINCIPAL DUTY IS

 

 

 

 

 

 

 

 

 

 

 

2.

I

DO

DO NOT RECOMMEND THE APPLICANT.

 

 

 

 

3.REMARKS (Include your opinion as to his/her overall ability (to include leadership) and value to the service).

ENCLOSURES

ORGANIZATION

SIGNATURE

TYPED NAME, GRADE AND TITLE

APD LC v2.01ES

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