NATIONAL GUARD APPLICATION

NATIONAL GUARD APPLICATION REQUIRED SOURCE DOCUMENTS

BIRTH CERTIFICATE* SOCIAL SECURITY CARD* DRIVERS LICENSE HIGH SCHOOL DIPLOMA* HIGH SCHOOL TRANSCRIPTS* COLLEGE DIPLOMA* COLLEGE TRANSCRIPTS* MARRIAGE CERTIFICATE* DEPENDENTS BIRTH CERTIFICATES* DEPENDENTS SOCIAL SECURITY CARDS* COPY OF SPOUSE’S DRIVERS LICENSE DIVORCE DECREE CHILD SUPPORT/CUSTODY DOCUMENTS MEDICAL DOCUMENTS COURT DOCUMENTS BANKRUPTCY DISCHARGE PAPERWORK I-551 Prior Service Documents (DD214, discharge orders, etc..)

Other ____________________ *

Must be Original or Certified Copy

RECRUITER INFORMATION:

SSG N. Kahle Wright 2060 N High St, Suite N Columbus, Ohio 43201 CELL: (614) 312-3016

[email protected]

FILL OUT EVERYTHING! FILL OUT EVERYTHING! FILL OUT EVERYTHING! FILL OUT EVERYTHING!

If you don’t know the answer to something, I need you to figure it out. Call a friend or family or look it up online. Take your time and read each line of this application. There are instructions with each section. It will take a bit of time to complete it all.

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680-3A-E/Personal Information

Last Name:____________________________ First:__________________________ Middle:_______________________

Male Female

Social Security Number: __________-_______-___________

Education: School: ________________________________________ Grad Year:_____________

Date of Birth: _______________________ Place of Birth: City____________________

State: ___________ County: ________________________

Phone Number: Cell________________________________ Home Number: _________________________________

Email: ____________________________________________________________________________________________

Address: Street: ____________________________________________________City: ____________________________

County: _____________________ State : __________ Zip: ____________

Primary Race: ___________________ Ethnic Category: ______________________Religion: ______________________

Drivers License # _________________________ State: ____________________ Expires: _________________________

Married Status: Never Married Married Divorced Separated Widowed

Children: Yes No Ages: __________________________ Registered to Vote: Yes No

Citizenship: US Native born US Born Abroad Immigrant Alien Alien Number__________________________

Height:________________ Weight:________________

Eye Color: ________________ Hair Color: ______________ Females Only-Last Menstrual Period___________________

Prior Service: Yes No

Branch: ________________ RE-Code:_________ Enlistment Date: ________________ Discharge Date: _____________

MOS: ___________ Pay Grade: _____________ Date of Rank: ______________ Discharge Type: ___________________

SSG N. Kahle Wright

Ohio State University Storefront

2060 N High St, Suite N

Columbus, Ohio 43201

CELL: 614-312-3016

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PHYSICAL SCREENING CRITERIA

Be completely honest when answering these questions. Take your time and read EACH question. Simply circle YES or NO. All yes answers will require and explanation at the end of this section. Give as much details as you can, dates, doctor’s names, hospital name, what happened, etc….. Hospital visits will require medical documentation. Start looking for them, call parents or request them from hospital or doctor.

1. Asthma, wheezing or inhaler use YES NO 2. Dislocated joint, including knee, hip, shoulder, elbow, ankle, or other joint YES NO 3. Epilepsy fits, seizures, or convulsions YES NO 4. Sleepwalking YES NO 5. Recurrent neck or back pain YES NO 6. Rheumatic Fever YES NO 7. Foot pain YES NO 8. A swollen, painful, or dislocated joint or fluid in a joint (knee, shoulder, wrist, elbow, etc.) YES NO 9. Double vision YES NO 10. Periods of unconsciousness YES NO 11. Frequent or severe headaches causing loss of time from work or school or taking YES NO

medication to prevent frequent or severe headaches12. Wear contact lenses (If so, bring your contact lens kit and solution so you can remove YES NO

your contact when we test your vision at the MEPS; also, if you have a pair of eyeglasses,bring them with you no matter how old they are.)

13. Fainting spells or passing out YES NO 14. Head injury, including skull fracture, resulting in concussion, loss of consciousness, YES NO

headaches, etc.15. Back surgery YES NO 16. Seen a psychiatrist, psychologist, social worker, counselor or other professional for any YES NO

reason (inpatient or outpatient) including counseling or treatment for school, adjustment,family, marriage or any other problem, to include depression, or treatment for alcohol,drug or substance abuse

17. Skin disease: Eczema YES NO 18. Skin disease: Psoriasis YES NO 19. Skin disease: Atopic Dermatitis YES NO 20. Irregular heartbeat, including abnormally rapid or slow heart rates YES NO 21. Allergic to bee, wasp, or other insects stings YES NO22. Heart murmur, valve problem or mitral valve prolapsed YES NO 23. Allergic to wool YES NO 24. Heart surgery YES NO 25. Been rejected for military service (temporary or permanent) for medical or other reasons YES NO 26. Any other heart problems YES NO 27. High blood pressure YES NO 28. Discharged from military service for medical reasons YES NO 29. Ulcer (stomach, duodenum, or other part of intestine) YES NO 30. Received disability compensation for an injury or other medical condition YES NO 31. Hepatitis (liver infection or inflammation) YES NO 32. Intestinal obstruction (locked bowels), or any other chronic or recurrent intestinal problem, YES NO

including small intestine or colon problems, such as Crohn's disease or Colitis33. Detached retina or surgery for a detached retina YES NO 34. Surgery to remove a portion of the intestine (other than the appendix) YES NO 35. Any other eye conditions, injury or surgery YES NO 36. Gall bladder trouble or gall stones YES NO 37. Jaundice YES NO 38. Missing a kidney YES NO 39. Allergy to common food (milk, bread, eggs, meat, fish, or other common food) YES NO 40. (Males only) Missing a testicle, testicular implant, or un-descended testicle YES NO 41. Broken bone requiring surgery to repair (with or without pins, plates, screws, or other YES NO

metal fixation devices used in repair)42. Ruptured or bulging disk in your back or surgery for a ruptured or bulging disk YES NO 43. Thyroid condition or take medication for your thyroid YES NO 44. Limitation of motion of any joint, including knee, shoulder, wrist, elbow, hip, or other joint YES NO 45. Drug or alcohol rehab YES NO 46. Kidney, urinary tract or bladder problems, surgery, stones, or other urinary tract problems YES NO 47. Sugar, protein, or blood in urine YES NO 48. Surgery on a bone or joint (knee, shoulder, elbow, wrist, etc.) including Arthroscopy with YES NO

normal findings49. Taking any medications YES NO 50. Pain or swelling at the site of an old fracture YES NO 51. Perforated ear drum or tubes in ear drum(s) YES NO

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52. Anemia YES NO 53. Ear surgery, to include mastiodectomy or repair of perforated ear drum, YES NO

hearing loss or need/use a hearing aid 54. Night blindness YES NO 55. Arthritis YES NO 56. Absence or disturbance of the sense of smell YES NO 57. Absence or removal of spleen, or rupture or tear of the spleen without removal YES NO 58. Anorexia or other eating disorder YES NO 59. Cracked bone or fracture(s) YES NO 60. Bursitis YES NO 61. Braces (If you wear or are planning on obtaining braces for your teeth, have the YES NO

orthodontist submit a letter stating that braces will be removed before active duty date; release form and sample format can be found in the Recruiter's Medical Guide.)

62. Loss of finger, toe, or part thereof YES NO 63. Loss of the ability to fully flex (bend) or fully extend a finger, toe, or other joint YES NO 64. Shoulder, knee, or elbow problem (out of place) YES NO 65. Locking of the knee or other joint YES NO 66. Giving way of knee or other joint YES NO 67. Cataracts or surgery for cataracts YES NO 68. Eye surgery, including radical keratotomy, lens implant or other eye surgery to improve YES NO

your vision 69. Collapsed lung or other lung condition YES NO 70. Bed wetting since age 12 YES NO 71. Evaluation, treatment, or hospitalization for alcohol abuse, dependence, or addiction YES NO 72. Do you use any tobacco products? YES NO

What kind_______________________________ How many a day___________________ 73. Evaluation, treatment, or hospitalization for substance use, abuse, addiction or YES NO

dependence (including illegal drugs, prescription medications, or other substances) 74. Taken medication, drugs, or any substance to improve attention, behavior, YES NO

or physical performance 75. Any illness, surgery, or hospitalization not listed above YES NO 76. Do you have a current insurance provider YES NO 77. Have you had a previous insurance provider YES NO 78. Do you have a primary care physician YES NO 79. Have you had a previous primary care physician YES NO 80. Painful or ‘trick’ joints or loss of movement in any joint YES NO 81. Do you have tattoos? YES NO 82. Do you have any body piercings? YES NO 83. Do you have any brandings? YES NO 84. Any deformities of, or missing fingers or toes YES NO

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PART II Have you ever had or do you now have any of the below

1. Tuberculosis? YES NO 2. Lived with someone who had tuberculosis? YES NO 3. Coughed up blood? YES NO 4. Asthma or any breathing problems related to exercising, weather or pollen? YES NO 5. Shortness of breath? YES NO 6. Bronchitis? YES NO 7. Wheezing or problems with wheezing? YES NO 8. Been prescribed or used an inhaler any time in your life? YES NO 9. A chronic cough or cough at night? YES NO 10. Sinusitis? YES NO 11. Hay Fever? YES NO 12. Severe tooth or gum trouble? YES NO 13. Thyroid trouble or goiter? YES NO 14. Eye disorder or trouble? YES NO 15. Ear, nose or throat trouble? YES NO 16. Loss of vision in either eye? YES NO 17. Worn contact lenses or glasses? YES NO 18. A hearing loss or wear a hearing aid? YES NO 19. Surgery to correct vision? (RK, PRK, LASIK, etc..) YES NO 20. Painful Shoulder, elbow or wrist (e.g. pain, dislocation, etc..) YES NO 21. Arthritis, rheumatism or bursitis? YES NO 22. Recurrent back pain or any back problem? YES NO 23. Foot trouble (e.g. pain, corns, bunions, etc…) YES NO 24. Impaired use of arms, legs, hands or feet? YES NO 25. Swollen or painful joints? YES NO 26. Knee trouble (e.g. locking, giving out, pain or ligament injury, etc…) YES NO 27. Any knee or foot surgery including arthroscopy or use of a scope to any bone or joint? YES NO 28. Any need to use corrective devices such as prosthetic devices, knee braces, back support? YES NO 29. Bone, joint or other deformity? YES NO 30. Plate, screws, rods or pins in any bone? YES NO 31. Broken bones (cracked or fractured)? YES NO 32. Frequent indigestion or heartburn? YES NO 33. Stomach, liver, intestinal trouble or ulcer? YES NO 34. Gall bladder trouble or gallstones? YES NO 35. Rupture hernia? YES NO 36. Rectal disease, hemorrhoids or blood from rectum? YES NO 37. Skin diseases (e.g. acne, eczema, psoriasis, etc…) YES NO 38. Frequent or painful urination? YES NO 39. High or low blood sugar? YES NO 40. Kidney stone or blood in urine? YES NO 41. Sugar or protein in urine? YES NO 42. Sexually transmitted disease (syphilis, gonorrhea, Chlamydia, genital warts, herpes, etc…) YES NO 43. Adverse reaction to serum, food, insect stings or medicine? YES NO 44. Recent unexplained gain or loss of weight? YES NO 45. Tumor, growth, cyst or cancer? YES NO 46. Dizziness or fainting spells? YES NO 47. Frequent or severe headaches? YES NO 48. A head injury, memory loss or amnesia? YES NO 49. Paralysis? YES NO 50. Seizures, convulsions, epilepsy or fits? YES NO 51. Car, train, sea or air sickness? YES NO 52. A period of unconsciousness or concussion? YES NO 53. Meningitis, encephalitis or other neurological problems? YES NO 54. Rheumatic fever? YES NO 55. Prolonged bleeding (as after an injury or tooth extraction, etc…) YES NO 56. Pain or pressure in the chest? YES NO 57. Palpitation, pounding heart or abnormal heartbeat? YES NO 58. Heart trouble or murmur? YES NO 59. High or low blood pressure? YES NO 60. Nervous trouble of any sort (anxiety or panic attacks) YES NO 61. Habitual stammering or stuttering? YES NO 62. Loss of memory or amnesia or neurological symptoms? YES NO 63. Frequent trouble sleeping? YES NO 64. Received counseling of ANY type? YES NO 65. Depression or excessive worry? YES NO 66. Been evaluated or treated for a mental condition? YES NO 67. Attempted suicide? YES NO

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68. Used illegal drugs or abused prescription drugs (to include weed or cocaine, etc….)? YES NO 69. Treatment for gynecological female disorder? FEMALES ONLY YES NO 70. A change of menstrual pattern? FEMALES ONLY YES NO 71. Any abnormal PAP smears? FEMALES ONLY YES NO 72. Have you ever had an abortion or miscarriage? FEMALES ONLY YES NO 73. Have you been refused employment or been unable to hold a job or stay in school because of:

A. Sensitivity to chemicals, dust, sunlight, etc… YES NO B. Inability to perform certain motions YES NO C. Inability to stand, sit, kneel, lie down, etc… YES NO D. Other medical reasons? YES NO

74. Have you ever been treated in an Emergency Room? YES NO 75. Have you ever been a patient in any type of hospital? YES NO 76. Have you ever been advised to have any operations or surgery? YES NO 77. Have you consulted or been treated by clinics, physicians, healers, or other practitioners YES NO

within the past 5 years for other illnesses?78. Have you ever received, is there pending, or have you ever applied for compensation for YES NO

any disability or injury?79. Have you ever been denied life insurance? YES NO 80. Do you have any scars that healed on their own or with stitches? YES NO 81. Have you ever been told you have asthma? YES NO 82. Are you color blind? YES NO 83. Ever had your tonsils removed? YES NO 84. Ever had your wisdom teeth removed? YES NO 85. Have you ever had your appendix removed? YES NO 86. Have you ever had a cyst removed? YES NO 87. Have you ever been X-rayed? YES NO 88. Have you ever had a mole removed? YES NO 89. Ever been diagnosed ADD or ADHD? YES NO 90. Are you allergic to anything? YES NO 91. Have you ever been suspended from school? YES NO 92. Have you ever been fired from any job? YES NO 93. Have you ever been kicked out of your home? YES NO

How often do you have a drink containing alcohol? Never Monthly or less 2-4 times a month 2-3 times week

How many drinks containing alcohol do you have on a typical day? 1-2 3-4 5-6 7-9 10 or more

How often do you have 6 or more drinks on one occasion? Never Less than monthly Monthly 2-3 times a week

EXPLANATIONS Any and all “YES” answers from above questions require an explanation. (Include question number and dates, doctor’s names, hospitals, what happened, etc…) As much as you can remember.

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PERSONAL SCREENING CRITERIA

1. Do you have a previous marriage? YES NO2. Have you ever been divorced? YES NO3. Are you legally separated? YES NO4. Did you have a marriage annulled? YES NO5. Have you been widowed? YES NO6. Do you presently reside with a cohabitant? YES NO7. Have you used any other names? YES NO8. Have you fathered/mothered any children? YES NO9. Is anyone dependent upon you for financial support? YES NO10. Do you have custody of any minor children? YES NO11. Have you relinquished custody of any child/children? YES NO12. Is there any court order or judgment in effect that directs you to provide alimony YES NO

and/or child support?13. Have you served in any branch of Armed Services to include the National Guard? YES NO14. Been rejected for military service (temporary or permanent) for medical or other reasons? YES NO15. Do you have an immediate relative (father, mother, brother or sister) who:

(1) is now a prisoner of war or is missing in action (MIA); YES NO (2) died or became 100% permanently disabled while serving in the Armed Services?

16. Are you the only living child in your immediate family? YES NO17. Have you ever been rejected for enlistment, reenlistment, or induction by any branch of the YES NO

Armed Forces of the United States?

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MORAL SCREENING CRITERIA

This Question is related to your Security Clearance. Have any of the following happened? (If 'Yes', you will be asked to provide details for each offense that pertains to the actions that are identified below.)

• In the past seven (7) years have you been issued a summons, citation, oragainst you? (Do in court in a criminal not check if all the citations involved traffic infractionswhere the fine was less than $300 and did not include alcohol or drugs) YES NO

• In the past seven (7) years have you been arrested by any police officer, sheriff, marshal orany other type of law enforcement official?

• In the past seven (7) years have you been charged, convicted, or sentenced of a crime in anycourt? (Include all qualifying charges, convictions or sentences in any Federal, state, local, military,or non-U.S. court, even if previously listed on this form).

• In the past seven (7) years have you been or are you currently on probation or parole?• Are you currently on trial or awaiting a trial on criminal charges?

This Question is related to your Security Clearance.

Other than those offenses already listed, have you EVER had the following happen to you?

• Have you EVER been convicted in any court of the United States of a crime, sentenced toimprisonment for a term exceeding 1 year for that crime, and incarcerated as a result of thatsentence for not less than 1 year? (Include all qualifying convictions in Federal, state, local,or military court, even if previously listed on this form.)

YES NO • Have you EVER been charged with any felony offense? (Include those under the Uniform Code

of Military Justice and nonmilitary/civilian felony offenses.)• Have you EVER been convicted of an offense involving domestic violence or a crime of violence

(such as battery or assault) against your child, dependent, cohabitant, spouse, former spouse,or someone with whom you share a child in common?

• Have you EVER been charged with an offense involving firearms or explosives?• Have you EVER been charged with an offense involving alcohol or drugs?

This Question is related to your Enlistment Eligibility.

Other than those offenses already listed, have any of the following happened? (If 'Yes', you will be asked to provide details for each offense that pertains to the actions that are identified below.)

• Have you EVER been issued a summons, citation, or ticket to appear in court in a proceedingagainst you? (Include all traffic infractions regardless of the fine amount.)

• Have you EVER been arrested by any police officer, sheriff, marshal or any other type of law YES NO enforcement official?

• Have you EVER been charged, convicted, or sentenced of a crime in any court? (Include allqualifying charges, convictions or sentences in any Federal, state, local, military, or non-U.S.court, even if previously listed on this form.)

• Have you EVER been or are you currently on probation or parole?

Is there currently a domestic violence protective order or restraining order issued against you? YES NO

In the last seven (7) years, have you consulted with a health care professional regarding an emotional or mental health condition or were you hospitalized for such a condition? Answer 'No' if the YES NO counseling was for any of the following reasons and was not court ordered: 1) strictly marital, family, grief not related to violence by you; or 2) strictly related to adjustments from service in a military combat environment.

In the last ten (10) years, have you been a party to any public record civil court action not listed YES NO elsewhere on this form?

Has your use of alcoholic beverages (such as liquor, beer, wine) resulted in any alcohol-related YES NO treatment or counseling (such as for alcohol abuse or alcoholism)?

In the last seven (7) years has your use of alcohol had a negative impact on your work performance, your professional or personal relationships, your finances, or resulted in intervention YES NO by law enforcement/public safety personnel?

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Have you EVER been ordered, advised, or asked to seek counseling or treatment as a result of YES NO your use of alcohol?

Have you EVER voluntarily sought counseling or treatment as a result of your use of alcohol? YES NO

Have you EVER received counseling or treatment as a result of your use of alcohol in addition to YES NO what you have already listed on this form?

In the last seven (7) years, have you illegally used any drugs or controlled substances? Use of a YES NO drug or controlled substance includes injecting, snorting, inhaling, swallowing, experimenting with or otherwise consuming any drug or controlled substance.

In the last seven (7) years,have you been involved in the illegal purchase, manufacture, cultivation, trafficking, production, transfer, shipping, receiving, handling or sale of any drug or YES NO controlled substance?

Have you EVER illegally used or otherwise been involved with a drug or controlled substance while YES NO possessing a security clearance other than previously listed?

Have you EVER illegally used or otherwise been involved with a drug or controlled substance while employed as a law enforcement officer, prosecutor, or courtroom official; or while in a position directly YES NO and immediately affecting the public safety other than previously listed?

In the last seven (7) years have you intentionally engaged in the misuse of prescription drugs, YES NO regardless of whether or not the drugs were prescribed for you or someone else?

Have you EVER been ordered, advised, or asked to seek counseling or treatment as a result of your YES NO illegal use of drugs or controlled substances?

Have you EVER voluntarily sought counseling or treatment as a result of your use of a drug or YES NO controlled substance?

Have you ever tried, used, sold, supplied, or possessed any narcotic (to include heroin or cocaine), depressant (to include quaaludes), stimulant, hallucinogen (to include LSD or PCP), or cannabis YES NO (to include marijuana or hashish), or any mind-altering substance (to include glue or paint), or anabolic steroid, except as prescribed by a licensed physician?

When was the last time you smoked weed? __________________ Last time you smelled it? ___________________

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FAIR CREDIT REPORTING DISCLOSURE AND AUTHORIZATION

DisclosureOne or more reports from consumer reporting agencies may be obtained for employment purposes pursuant to the Fair Credit Reporting Act, codified at 15 U.S.C. § 1681 et seq.

AuthorizationI hereby authorize the investigative agency conducting my background to obtain such reports from any consumer reporting agency for employment purposes described above. Note: If you have a security freeze on your consumer or credit report file, then we may not be able to complete your investigation, which can adversely affect your eligibility for a national security position. To avoid such delays, you should request that the consumer reporting agencies lift the freeze in these instances.

YES NO

Information on any tickets or charges you had against you. Traffic, non-traffic, misdemeanor or felonies.

Date of Offense____________

Charge_____________________ Disposition______________________ Fine Amount__________________

Ticketing or Arresting Department_______________________City__________________County___________State________

Court ticket or case was overseen_______________________________________________

Court Address_____________________City___________________County________________State___________





















LAW VIOLATION EXPLANATIONS: ENTER ANY ADDITIONAL INFORMATION NEEDED

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TECHNOLOGY INFORMATION

Have you illegally or without proper authorization entered into any information technology system? YES NO

Have you illegally or without proper authorization modified, destroyed, manipulated, or denied others YES NO access to information residing on an information technology system?

Have you introduced, removed, or used hardware, software, or media in connection with any YES NO information technology system without authorization, when specifically prohibited by rules, procedures, guidelines, or regulations?

GROUP /MEMBER ASSOCIATIONS

Are you now or have you EVER been a member of an organization dedicated to terrorism, YES NO either with an awareness of the organization's dedication to that end, or with the specific intent to further such activities?

Have you EVER knowingly engaged in any acts of terrorism? YES NO

Have you EVER advocated any acts of terrorism or activities designed to overthrow the U.S. YES NO Government by force?

Have you EVER been a member of an organization dedicated to the use of violence or force to overthrow the United States Government, and which engaged in activities to that end with an YES NO awareness of the organization's dedication to that end or with the specific intent to further such activities?

Have you EVER been a member of an organization that advocates or practices commission of acts YES NO of force or violence to discourage others from exercising their rights under the U.S. Constitution or any state of the United States with the specific intent to further such action?

Have you EVER knowingly engaged in activities designed to overthrow the U.S. Government by force? YES NO

Have you EVER associated with anyone involved in activities to further terrorism? YES NO

Aliases Full Name __________________________________ From-To Dates ___________________________________

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RESIDENSES We need you to go back 10 years or to your 16th birthday. There is a reference required with eachlocation. Must not be someone already used in this application and non-family. Can be a neighbor or maybe a friend of your parents. Simply someone that can verify you lived there. No gaps in dates.

Current Address: ___________________________ City____________________ State_________ Zip______________

County__________________________ Rent Own

Date moved into address: Month__________ Day_________ Year__________

Reference Name: First________________ Middle__________ Last__________________ How you know them__________

Reference Address:_________________________ City____________________ State _________ Zip______________

Reference Phone Number_______________________ Reference County __________________________

Former Address: ___________________________ City____________________ State_________ Zip______________

County__________________________ Rent Own

Date moved into address: Month__________ Day_____ Year_________ Moved out: Month ________ Day____ Year_____

Reference Name: First________________ Middle__________ Last__________________ How you know them__________




County__________________________ Rent Own


Reference Name: First________________ Middle__________ Last __________________ How you know them __________




County__________________________ Rent Own


Reference Name: First________________ Middle ___________ Last __________________ How you know them _________



Do you speak, read, understand or write a foreign language fluently?

YES NO

If so, which______________________________________________

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EMPLOYMENT HISTORY Include all information. If you don’t know it, look it up online or call the establishment. Weneed you to go back 10 years or to your 16th birthday. Start with current or most recent and work back.

Employer _____________________________ Supervisor Name: First_________________ Last____________________

Date started: Month______________ Day______ Year________ Date Left: Month_________ Day_____ Year_________

Position title______________________________ Position Responsibilities__________________________________

Full Time Part Time Hours worked______________

Employer Address: ________________________ City____________________ State_________ Zip_______________

Phone Number_____________________ Employer County__________________ Position____________________

Reason For Leaving__________________________________________________



Position title________________________________ Position Responsibilities__________________________________







Position title_________________________________ Position Responsibilities__________________________________







Position title___________________________________ Position Responsibilities__________________________________





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PRIOR SERVICE This section is for people that have been in the military before.

Service Branch_____________________________ Officer or Enlisted _______________Rank at discharge______________

Service Status: Active Active Reserve Inactive Reserves.

Highest rank acquired _______________ Date of Rank______________________

From Date: Month____________ Day_______ Year________ To Date: Month_____________ Day_______ Year________

Discharge Type__________________ Narrative Reason ______________________________________ SPD Code________

RE Code_________ MOS or Specialty Job code______________ Unit Name_____________________________________

Unit Address______________________ City__________________ State_______ Zip_____________ Country___________

Supervisor Name: First_________________ Last_____________________ Rank ___________Phone Number____________

FOREIGN HISTORY

Have you, your spouse, cohabitant, or dependent children EVER had any foreign financial interests (such as stocks, property, investments, bank accounts, ownership of corporate entities, corporate interests or businesses) in which you or have direct control or direct ownership? (Exclude financial interests in companies or diversified mutual funds that are publicly traded on a U.S. exchange.)

YES NO

YES NO

YES NO

Have you, your spouse, cohabitant, or dependent children EVER had any foreign financial interests that someone controlled on your behalf?

YES NO

YES NO

YES NO

Do you have or have you had close continuing contact with foreign nationals within the last 10 years with whom you, your spouse, or your cohabitant are bound by affection, influence, and/or obligation? Include associates, as well as relatives, not already listed. (A foreign national is defined as any person who is not a citizen or national of the U.S.)

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Have you, your spouse, cohabitant, or dependent children EVER owned, or do you anticipate owning, or plan to purchase real estate in a foreign country?

As a U.S. citizen, have you, your spouse, cohabitant, or dependent children received in the past seven (7) years, or are eligible to receive in the future, any educational, medical, retirement, social welfare, or other such benefit from a foreign country?

YES NO

Have you EVER provided financial support for any foreign national? YES NO

Have you in the past seven (7) years provided advice or support to any individual associated with a foreign business or other foreign organization that you have not previously listed as a former employer? (Answer 'No' if all your advice or support was authorized pursuant to official U.S. Government business.)

Have you, your spouse, cohabitant, or any member of your immediate family in the past seven (7) years been asked to provide advice or serve as a consultant, even informally, by any foreign government official or agency? (Answer 'No' if all the advice or support was authorized pursuant to official U.S. Government business.) For this question, "Immediate Family" means your spouse, parent, step-parents, siblings, half and step-siblings, children, step-children, and cohabitant.

Has any foreign national in the past seven (7) years offered you a job, asked you to work as a consultant, or consider employment with them? YES NO

Has any foreign national in the past seven (7) years offered you a job, asked you to work as a consultant, or consider employment with them?

Have you in the past seven (7) years attended or participated in any conferences, trade shows, seminars, or meetings outside the U.S.? (Do not include those you attended or participated in on official business for the U.S. government.)

YES NO

YES NO

Have you traveled outside the US in the last 10 years? (For other than military travel)

Country___________________ From Date___________________ To Date_________________ Reason______________



Have you in the past seven (7) years attended or participated in any conferences, trade shows, seminars, or meetings outside the U.S.? (Do not include those you attended or participated in on official business for the U.S. government.)

Have you in the past seven (7) years sponsored any foreign national to come to the U.S. as a student, for work, or for permanent residence?

Have you EVER held political office in a foreign country?

Have you EVER voted in the election of a foreign country?

Have you EVER been issued a passport (or identity card for travel) by a country other than the U.S.?

YES NO

YES NO

YES NO

YES NO

YES NO

PROVIDE A DETAILED EXPLANTION FOR ANY “YES” ANSWERS

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BACKGROUND / INVESTIGATION

Have you EVER served in the U.S. military? YES NO

Have you EVER served in a foreign country's military, security forces, YES NO militia, or other defense forces?

Have you EVER received a discharge that was not honorable? YES NO

Have you ever been subject to court martial or other disciplinary proceedings under the Uniform YES NO Code of Military Justice? (Include non-judicial, Captain's mast, etc.)

Are you now or have you ever been a deserter from any branch of the armed forces? YES NO

Have you ever been employed by the United States Government? YES NO

Are you now drawing, or do you have an application pending, or approval for: retired pay, disability YES NO allowance, severance pay, or pension from any agency of the government of the United States?

Are you now or have you ever been a conscientious objector? (That is, do you have, or have you YES NO ever had, a firm, fixed, and sincere objection to participation in war in any form or to the bearing of arms because of religious belief or training?)

Is there anything which would preclude you from performing military duties or participating in YES NO military activities whenever necessary (i.e., do you have any personal restrictions or religious practices which would restrict your availability?)

Have you ever been discharged by any branch of the Armed Forces of the United States for reasons YES NO pertaining to being a conscientious objector?

Have you ever been an officer or a member or made a contribution to an organization dedicated to the YES NO violent overthrow of the United States Government and which engages in illegal activities to that end, knowing that the organization engages in such activities with the specific intent to further such activities?

YES NO Have you ever knowingly engaged in any acts or activities designed to overthrow the United States Government by force?

YES NO

To your knowledge, have you EVER had a clearance or access authorization denied, suspended, or revoked; or been debarred from government employment? [If "Yes," give the action(s) date(s), of action(s), agency(ies), and circumstances.] Note: An administrative downgrade or termination of a security clearance is not a revocation.

Has the U.S. Government or a foreign government EVER investigated your background and/or

YES NO

granted you a security clearance?

Are you a male born after December 31, 1959?

YES NO

If yes, go to www.sss.gov and check your registration number. Simply input the basic information about yourself. You only need your name, birthday and social security number. If it doesn’t have one for you, register for one. It’s instant.

Registration Number from SSS____________________________________________

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YES NO

Have you EVER been debarred from government employment?

http://www.sss.gov/

EDUCATION

Have you attended any schools in the last 10 years? YES NO

Highest Grade Completed?___________________ Highest Education Level?________________________________

Did you graduate from a traditional HS YES NO

Do you have a post-secondary certificate or diploma? YES NO

Have you ever been enrolled in ROTC, Junior ROTC, Sea Cadet Program or Civil Air Patrol? YES NO

School Name_______________________________ Education Type ________________ From _________To ___________

Graduated? YES NO Type of Degree/Diploma Obtained_________________ Grad Date ____________ Credits _______

School Location: Street________________________________City_______________State_________Zip Code__________

Guidance Counselor: Last Name ___________________First Name __________________ Middle Name ____________

Address: Street_______________________________City_______________State__________Zip Code_____________

Phone Number__________________________ Email______________________________________________________

School Name__________________________________ Education Type ________________ From _________ To _______

Graduated? YES NO Type of Degree/Diploma Obtained___________________ Grad Date ____________ Credits _____


Registar: Last Name ___________________ First Name __________________ Middle Name ___________



School Name__________________________________ Education Type ________________ From _________ To _______

Graduated? YES NO Type of Degree/Diploma Obtained___________________ Grad Date ____________ Credits _____


Registar: Last Name ___________________ First Name __________________ Middle Name ___________



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Do you have any Studen Loans? YES NO How Much in Federal Loans?_____________ FAFSA 4 digit PIN Number ___________

FINANCIAL HISTORY

In the last seven (7) years have you filed a petition under any chapter of the bankruptcy code? YES NO

Have you EVER experienced financial problems due to gambling? YES NO

In the past seven (7) years have you failed to file or pay Federal, state, or other taxes when YES NO required by law or ordinance?

In the past seven (7) years have you been counseled, warned, or disciplined for violating the YES NO terms of agreement for a travel or credit card provided by your employer?

Are you currently utilizing, or seeking assistance from, a credit counseling service or other similar YES NO resource to resolve your financial difficulties?

Other than previously listed, have any of the following happened to you? (You will be asked to provide details about each financial obligation that pertains to the items identified below).

• In the past seven (7) years, you have been delinquent on alimony or child supportpayments.

• In the past seven (7) years, you had a judgement entered against you. (Includefinancial obligations for which you were the sole debtor, as well as those for which youwere a cosigner or guarantor.)

YES NO • In the past seven (7) years, you had a lien placed against your property for failing to

pay taxes or other debts. (Include financial obligations for which you were the sole debtor,as well as those for which you were a cosigner or guarantor).

• You are currently delinquent on any Federal debt. (Include financial obligations for which youare the sole debtor, as well as those for which you are cosigner or guarantor).

Other than previously listed, have any of the following happened?

• In the past seven (7) years, you had any possessions or property voluntarily orinvoluntarily repossessed or foreclosed? (Include financial obligations for which youwhere the sole debtor as well as those where you were a cosigner or guarantor)

• In the past seven (7) years, you defaulted on any type of loan? (Include financialobligations for which you where the sole debtor as well as those where you were acosigner or guarantor)

• In the past seven (7) years, you had bills or debts turned over to a collectionagency? (Include financial obligations for which you where the sole debtor as well asthose where you were a cosigner or guarantor)

• In the past seven (7) years, you had any account or credit card suspended, charged YES NO off, or cancelled for failing to pay as agreed? (Include financial obligations for which youwhere the sole debtor as well as those where you were a cosigner or guarantor)

• In the past seven (7) years, you were evicted for non-payment?• In the past seven (7) years, you had your wages, benefits, or assets garnished or

attached for any reason?• In the past seven (7) years, you have been over 120 days delinquent on any debt not

previously entered? (Include financial obligations for which you where the sole debtor aswell as those where you were a cosigner or guarantor)

• You are currently over 120 days delinquent on any debt? (Include financial obligations forwhich you where the sole debtor as well as those where you were a cosigner or guarantor)

PROVIDE A DETAILED EXPLANTION FOR ANY “YES” ANSWERS

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YOUR SPOUSE

Current Spouse Name: First_________________________ Middle______________ Last____________________________

Social Security Number___________________ Date of Birth________________ Citizenship__________________________

Place of Birth: City___________________________ State_____________ Spouse ever been in military? YES NO

Date Married: Month_________ Day______ Year_______

Place married: City___________________ State_____________ County____________________

Spouse Maiden Name_____________________ Dates had maiden name: From_____________ To______________

FORMER SPOUSE

Former Spouse Name: First__________________________ Middle_________________ Last________________________

Date of Birth: Month____________ Day________ Year________ Citizenship_________________________

Date Married: Month________ Day_____ Year_______ Place Married: City____________ State______ County__________

Place of Birth: City___________________________ State__________ Divorced/Widowed? YES NO

Date of Divorce/Widowed: Month__________ Day_______ Year______

Divorce Records Located Where: City_________________ State_________ County_______________ Zip_____________

Address of Former Spouse_______________________ City______________ State_______ Zip_________ County________

Phone Number_____________________________

If you need another spot for more spouses, use the back of this page, include all information.

FAMILY & ASSOCIATES

Information needed for: Children, Mother, Father, Step Mother, Step Father, any siblings (to include step-siblings or half sister or half brother). If you are married we do need your mother in-law and father in-law as well.

Name: First__________________ Middle_______________ Last__________________ Relationship ___Mother_____

Mother’s Maiden Name __________________________________ Date name used: From _____________ To ___________

Other Names Used:____________________________________ Date Name Used: From _____________ To ____________

Date of Birth: Month_________________ Day__________ Year_____________ Deceased YES NO

Name: First__________________ Middle_______________ Last__________________ Relationship ___Father_____

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Current Address_____________________________ City___________________ State_________ Zip____________

Place of Birth: City__________________________ State______________ Citizenship_______________________________

Cell Phone Number:____________________________________

Other Names Used _____________________________________ Date Name Used: From ___________ To ___________


Current Address_____________________________ City________________ State ______ County __________ Zip ______


Cell Phone Number:______________________________________

Name: First__________________ Middle_______________ Last__________________ Relationship___________________

Other Names Used _____________________________________ Date Name Used: From ___________ To ____________















Other Names Used _____________________________________ Date Name Used: From ___________ To ___________














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Cell phone number: _____________________________________






CITIZENSHIP

Do you possess a U.S. Passport (current or expired)? YES NO

Date passport issued: Day ________________ Month _______________ Year _________________

Date passport expires: Day ________________ Month _______________ Year _________________

Passport Number_____________________________________

Do you now hold or have you EVER held multiple citizenships? YES NO

BENEFICIARIES (Life Insurance)

You are offered life insurance through the National Guard. Pick one coverage amount. We need at least a primary and a secondary beneficiary. Pick someone from your family and associates list for each.

$50,000 ($4.25 a month) $100,000 ($7.50) $150,000 ($10.75) $200,000 ($14.00)

$250,000 ($17.25) $300,000 ($20.50) $350,000 ($23.75) $400,000 ($27.00)

Primary________________________________________ Secondary___________________________________________

CHARACTER REFERENCES We need three people that have known you for AT LEAST 10 years. They must be non-family and not used anywhere else in this application. (These 3 are your inner circle of friends or closest friends)

Name: First___________________ Middle__________________ Last___________________ Relationship ____________

Address: _______________________________________ City_________________ State____________ Zip____________

Phone Number____________________________ Date Since Known: Month__________ Day_________ Year___________

Email:______________________________________________________________________________________________




Email:______________________________________________________________________________________________




Email:______________________________________________________________________________________________

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