USMEPCOM Form 680-3A-E at a glance
What it is: USMEPCOM Form 680-3A-E is the Request for Examination; the information provided constitutes an official statement.
Who signs: Sign in Box 21, APPLICANT'S SIGNATURE.
A filled-in USMEPCOM Form 680-3A-E example: an applicant who was never tested with the ASVAB
How to fill out USMEPCOM Form 680-3A-E, box by box
Prior service, Selective Service classification and registration number
Enter B. PRIOR SERVICE as Yes with the NUMBER OF DAYS, or No, then C. SELECTIVE SERVICE CLASSIFICATION and D. SELECTIVE SERVICE REGISTRATION NUMBER.
Social Security Number, name, current address and home of record address
Enter your SOCIAL SECURITY NUMBER in Box 1.
Enter your NAME in Box 2: Last, First, Middle Name (and Maiden, if any), Jr., Sr., etc.
Enter your CURRENT ADDRESS in Box 3: Street, City, County, State, Country, ZIP Code.
Enter your HOME OF RECORD ADDRESS in Box 4: Street, City, County, State, Country, ZIP Code.
Citizenship, sex, ethnic category and racial category
In Box 5, CITIZENSHIP, X one; if a. U.S. AT BIRTH is marked, also X (1) NATIVE BORN or (2) BORN ABROAD OF U.S. PARENT(S).
CITIZENSHIP also lists b. U.S. NATURALIZED, c. U.S. NON-CITIZEN NATIONAL, d. IMMIGRANT ALIEN (Specify), e. NON-IMMIGRANT FOREIGN NATIONAL (Specify) and f. ALIEN REGISTRATION NUMBER (As applicable).
In Box 6, SEX, X one: a. MALE or b. FEMALE. In Box 7.a., ETHNIC CATEGORY, X one: (1) HISPANIC OR LATINO or (2) NOT HISPANIC OR LATINO.
In Box 7.b., RACIAL CATEGORY, X all that apply: (1) AMERICAN INDIAN/ALASKA NATIVE, (2) ASIAN, (3) BLACK OR AFRICAN AMERICAN, (4) NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER, (5) WHITE.
Marital status, number of dependents, date of birth and place of birth
Enter your MARITAL STATUS (Specify) in Box 8 and your NUMBER OF DEPENDENTS in Box 9.
Enter your DATE OF BIRTH (YYYYMMDD) in Box 10, your RELIGIOUS PREFERENCE (Optional) in Box 11 and your EDUCATION (Yrs/Highest Ed Gr completed) in Box 12; in Box 13, PROFICIENT IN FOREIGN LANGUAGE, X one (If Yes, specify).
In Box 14, VALID DRIVER'S LICENSE, X one (If Yes, list State, number, and expiration date). Enter your PLACE OF BIRTH (City, State, and Country) in Box 15.
Applicant's signature and applicant certification in presence of test administrator
Sign in Box 21, APPLICANT'S SIGNATURE.
Box 23, APPLICANT CERTIFICATION IN PRESENCE OF TEST ADMINISTRATOR: "I certify that I am the person identified on this form". Photo ID? (X one).
If Yes, enter the type/organization and the ID Number, then sign (Signature of Applicant).
Applicant certification in presence of recruiting personnel
Box 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:"
Mark 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.
Mark b. I was tested with the ASVAB on or about (Most Recent Date Tested) at (School, City, and State).
Mark c. Request for student test scores (high school look-up) at (Most Recent Date Tested) at (School, City, and State).
Mark d. Yes, I want to keep my AFQT scores from the student test listed in "c. Request for student test scores (high school look-up)".
Enter e. Current or last high school attended (High School) OR (13 Digit Code).
Sign f. (Signature of Applicant), with the (Date) and the (Social Security Number).
Medical records release, current medical insurer and current medical provider
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.
Enter your APPLICANT'S CURRENT MEDICAL INSURER NAME in Box 26 (If none, sign your complete name to affirm you have no current medical insurer).
Enter your APPLICANT'S CURRENT MEDICAL PROVIDER NAME in Box 27 (If none, sign your complete name to affirm you have no current medical provider).
Enter the MEDICAL INSURER ADDRESS in Box 28 and the MEDICAL PROVIDER ADDRESS in Box 29: Street, City, State, Country, ZIP Code.
More rules for USMEPCOM Form 680-3A-E
Military recruiters use the information you provide on this form to collect additional information from the individuals, schools, and employers you list so that military recruiters can determine if you meet recruitment standards.
Read Privacy Act Statement on back before completing form.
If you do meet these standards and enlist, the information you provide on this form starts your Official Military Personnel File.
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.
Sources
[1] USMEPCOM Form 680-3A-E (JUN 2015), Request for Examination (the Official source link on this page).