Usmepcom Form 680 3A E PDF Details

Navigating the enlistment process in the United States military involves a dedicated series of steps and documentation, with the USMEPCOM Form 680-3A-E playing a critical role for candidates. This vital document, governed by the USMEPCOM Regulation 680-3, is essentially a request for examination by individuals seeking to undergo medical and other examinations at a Military Entrance Processing Station (MEPS). It's structured to provide a comprehensive overview of an applicant's eligibility and suitability for service. Drawing authority from various sections of Title 10 U.S. Code and Executive Orders, the form requires detailed personal, medical, and educational information. Such specifics ensure that the MEPS can accurately process and identify each individual, facilitating a smooth transition into the enlistment process. Moreover, the form acts as a linchpin for maintaining enlistment processing records, underscoring its importance in the broader context of military recruitment and processing. It's designed with sections that accommodate an applicant’s personal identification details, such as Social Security number, name, citizenship, marital status, and more, along with information regarding their educational background, any prior service, and the necessary medical examination request to enlist. Compliance and truthful declaration on this form are crucial, as refusal to provide required data or misinformation could lead to denial of enlistment, underlining the form's role in ensuring that only thoroughly evaluated individuals are considered for service in the U.S. military.

QuestionAnswer
Form NameUsmepcom Form 680 3A E
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesform 680 3a e, blank 680 form, form 680, dd form 680

Form Preview Example

FOR USE OF THIS FORM, SEE USMEPCOM REG 680-3

REQUEST FOR EXAMINATION

THE INFORMATION PROVIDED CONSTITUTES AN OFFICIAL STATEMENT

FOR OFFICIAL USE ONLY

PRIVACY ACT STATEMENT AUTHORITY: Sections 505, 508, 510, and 3012 of Title 10 U.S. Code and Executive Order 9397. PRINCIPAL PURPOSE: The requested information on this form will be used

to properly process and identify the individual requesting an examination at a military entrance processing station (MEPS). ROUTINE USE: Record is maintained with other enlistment processing records.

DISCLOSURE: Voluntary; refusal to provide required data could result in denial of enlistment.

A. SERVICE PROCESSING FOR

B. PRIOR SERVICE

[ ] YES

[ ] NO

C. SELECTIVE SERVICE CLASSIFICATION

D. SELECTIVE SERVICE REGISTRATION NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NUMBER OF DAYS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

SOCIAL SECURITY NUMBER

 

 

2. NAME (Last, First, Middle Name (and Maiden, if any), Jr., Sr., etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.CURRENT ADDRESS

(Street, City, County, State, Country, ZIP Code)

5.CITIZENSHIP (X One)

4.HOME OF RECORD ADDRESS

(Street, City, County, State, Country, ZIP Code)

6.

SEX (X One)

7.a. RACIAL CATEGORY (X one or more)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. U.S. AT BIRTH (If this box is marked, also X (1) or (2))

 

 

 

 

 

 

 

 

 

 

a. MALE

 

 

 

 

(1) AMERICAN INDIAN/

 

 

 

 

 

 

 

 

 

(4) NATIVE HAWAIIAN OR OTHER

 

 

 

(1) NATIVE BORN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. FEMALE

 

 

 

 

 

ALASKA NATIVE

 

 

 

 

 

 

 

 

 

 

PACIFIC ISLANDER

 

 

 

(2)

BORN ABROAD OF U.S. PARENT(S)

 

 

 

 

 

8.

MARITAL STATUS

 

 

(2)

 

ASIAN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(5) WHITE

 

 

 

 

 

 

 

 

b. U.S. NATURALIZED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Specify)

 

 

 

 

 

 

(3) BLACK OR AFRICAN AMERICAN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. U.S. NON-CITIZEN NATIONAL

 

 

 

 

 

 

 

 

 

 

 

9.

NUMBER OF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d. IMMIGRANT ALIEN (Specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

DEPENDENTS

 

 

7.b. ETHNIC CATEGORY (X One)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e. NON-IMMIGRANT FOREIGN NATIONAL (Specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(1)

 

HISPANIC OR

 

 

 

 

(2)

 

NOT HISPANIC OR

 

 

 

 

 

 

 

 

 

f. ALIEN REGISTRATION NUMBER (As applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LATINO

 

 

 

 

 

 

 

 

 

 

LATINO

 

 

 

 

 

 

 

 

 

 

 

 

 

10.

DATE OF BIRTH (YYYYMMDD)

11. RELIGIOUS PREFERENCE (Optional)

12.

 

EDUCATION (Yrs/Highest Ed Gr Completed)

13.

PROFICIENT IN FOREIGN LANGUAGE (X One)

 

 

1st

2nd

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(If Yes, specify)

 

 

[

 

] YES [

] NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14.

VALID DRIVER'S LICENSE (X One)

 

[

] YES

[ ] NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15.

PLACE

OF BIRTH (City, State, and Country)

 

 

 

 

 

 

 

 

 

 

 

 

(If Yes, list State, number, and expiration date)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16. APTITUDE:

a. ASVAB REQUIRED TO ENLIST?

 

 

 

 

 

c. TEST TYPE

 

 

 

 

d. RETEST TYPE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e. PREVIOUS TEST VERSIONS

 

 

 

 

 

 

(X One)

[

] YES

[ ]

NO

 

[

]

INITIAL

 

 

 

 

[

]

1ST RETEST

[

 

] 6 MONTH RETEST

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

b. ENLIST UNDER STUDENT TEST SCORES?

 

[

]

SPECIAL

 

 

 

 

[

]

2ND RETEST

 

 

 

 

 

 

 

 

 

 

 

 

 

f. PREVIOUS TEST DATES (YYYYMMDD)

 

 

 

 

 

 

(X One)

[

] YES

[ ]

NO

 

[

]

CONFIRMATION

 

[

]

IMMED RETEST AUTHORIZED

 

 

 

 

 

 

 

 

 

1.

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17.

a. RECRUITER ID/SSN

 

 

b. STATION ID

 

18.

TEST ADMINISTRATOR SSN/ID

 

 

 

 

19.

 

TEST ADMINISTRATOR

 

 

SIGNATURE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20. MEDICAL: a. MEPS MEDICAL EXAM REQUIRED TO ENLIST?

 

 

 

b. EXAM TYPE [

]

FULL

 

[

]

SPECIAL

[

]

RE-EXAM

 

 

 

 

 

c. DATE LAST FULL MEDICAL EXAM

 

 

 

 

 

 

(X One)

[

] YES

[ ]

NO

 

 

 

 

 

 

 

 

[

]

INSPECT

[

]

CONSULT

[

]

OTHER

 

 

 

 

 

(YYYYMMDD)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21.

APPLICANT'S SIGNATURE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22.

 

 

 

 

 

 

 

 

 

 

 

 

MIRS CODING

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WKID

 

 

ST

 

 

 

 

DATE

 

INT

 

 

DATE

 

 

 

INT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

23.APPLICANT CERTIFICATION IN PRESENCE OF TEST ADMINISTRATOR

I certify that I am the person identified on this form:

Photo ID? (X One)

[ ] YES

[ ] NO

 

If yes, type/organization __________________________________

____________________________________________________________________

ID Number ______________________________________________

(Signature of Applicant)

25.APPLICANT CERTIFICATION IN PRESENCE OF RECRUITING PERSONNEL

I certify that I am the person identified on this form and the information about me shown there, including my Social Security Number is all true and correct to the best of my knowledge. I also certify that:

a.

 

I have never been tested ANYTIME or ANYWHERE with the ASVAB either for enlistment purposes or as a student under the ASVAB testing program.

b.

 

I was tested with the ASVAB on or about

_________________________________________ at ___________________________________________

 

 

 

 

(Most Recent Date Tested)

(School, City, and State)

c.

 

Request for student test scores (high school look-up)

_________________________________________ at ___________________________________________

 

 

 

 

(Most Recent Date Tested)

(School, City, and State)

d.

 

Yes, I want to keep my AFQT scores from the student test listed in "c" above.

 

e. Current or last high school attended ____________________________________________ / _____________________________________________________________

(High School)OR(13 Digit Code)

f. _________________________________________________________/________________________________________/_______________________________________________

(Signature of Applicant)

(Social Security Number)

(Date)

24.RIGHT THUMBPRINT

RIGHT THUMBPRINT, FIRST ATTEMPT (AFFIX THUMBPRINT WITH THUMBNAIL POINTED TO THE LEFT)

IF SECOND ATTEMPT IS REQUIRED, TURN FORM OVER (TOP OF FORM ON THE BOTTOM) AFFIX RIGHT THUMBPRINT ON UPPER RIGHT CORNER, THUMBNAIL POINTED TO THE LEFT

MEDICAL RECORDS RELEASE AUTHORITY: I request and authorize individuals/organizations listed below to release to the MEPS a complete transcript of my medical records. This release is for the purpose of further evaluation of my medical acceptability under military medical fitness standards. The medical records are to be obtained by this examinee at no cost to the Government and made available for review during the pre-enlistment physical.

26.

APPLICANT'S CURRENT MEDICAL INSURER NAME

 

 

27.

APPLICANT'S CURRENT MEDICAL PROVIDER NAME

 

 

(If none, sign your complete name to affirm you have no current medical insurer):

 

(If none, sign your complete name to affirm you have no current medical provider):

 

 

 

 

 

 

 

 

28.

MEDICAL INSURER ADDRESS

 

 

29.

MEDICAL PROVIDER ADDRESS

 

 

(Street, City, State, Country, ZIP Code)

 

 

 

(Street, City, State, Country, ZIP Code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

30.

CERTIFICATION BY RECRUITING PERSONNEL

 

 

 

 

 

APPLICANT SSN

I certify that I have properly identified this applicant in accordance with my service directives, have reviewed for completeness and accuracy the

 

information provided on this form, and have witnessed the applicant's signature:

 

 

 

 

_________________________________________________________________/__________________________________________________/_____________________________

 

 

 

(Signature of Recruiter (or rep, if auth))

(Printed/Typed Name of Recruiter or Rep)

(Date)

 

_________________________________________________________________

 

 

 

 

 

 

(Printed/Typed Name of Recruiter (if not recorded above))

 

 

 

 

 

 

____________________________________________________/____________________________________________/_____________________________________________

 

 

 

(Recruiter ID/SSN)

(Local Recruiting Activity)

 

(Bn, NRD, Sq or RS Location)

 

 

 

 

 

 

 

 

 

 

USMEPCOM Form 680-3A-E, OCT 05

Replaces USMEPCOM Form 680-3A-E, DEC 03, which is obsolete

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Writing section 1 in what is a 680 form

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3. In this specific stage, look at CERTIFICATION BY RECRUITING, APPLICANT SSN, Signature of Recruiter or rep if, PrintedTyped Name of Recruiter or, PrintedTyped Name of Recruiter if, Recruiter IDSSN Local Recruiting, USMEPCOM Form AE OCT, and Replaces USMEPCOM Form AE DEC. These must be filled out with utmost awareness of detail.

PrintedTyped Name of Recruiter or, PrintedTyped Name of Recruiter if, and USMEPCOM Form AE OCT in what is a 680 form

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