TF Application

AIR-SPACE-CYBERSPACE

Information in this packet is subject to the Privacy Act of 1974 and is for official use only

Americas Air Force AIRFORCE.COM

AIRFORCE.COM

Air Force Application Package

Accurate, legible, and detailed information in this application will ensure there are no delays in your process!

Read every section carefully and be truthful

AIR FORCE RECRUITING

THIS APPLICATION IS DUE BACK TO YOUR

RECRUITER BY:

Program Sub Program Specialty Briefed on Privacy Act Regerstered to Vote

Reviewed Applicable Films DD Form 2644

DD Form 2645

Lead SourceLead Date:

Date of Birth

Citzenship: #:

Race: Ethnicity:

Hair Color: Eye Color:

Foreign Languages:

/

Contact # Current Address:

Home of Record:

Driver's License #: ST:

Expiration Date:

Citizenship Prior Service

Conscientious Objector Education

Morals Dependents

Age Drugs

Physical SSN Verified

Waivers Required to join

Civil Court

Marital Status/DependentsMoralsFinancial RecordsEducationDrug UsePrior Service RecordsAdditional Residence

Religious Preferences:Height / Weight:

Email

PROCESSING PROGRAMS

DEMOGRAPHICSGender Verified SSN

Alien Registration:

Name (Last, First, MI, Maiden, Suffix): Maiden Name / Alias / Other Names

Medical Hx:

Law violations:

Drugs:

PERPETUATED LEADS:

Applicant PIR WorksheetBRIEFING ITEMS

Additional Comments: CCMAPPEDDS Verification (Y/N):

Place of Birth (City, St, Country):

Selective Service #:

Navigate to: (Digital App Only)

Law Violations Instructions The applicant is the primary source of information about criminal activities and law violations. Record all law violations (to include juvenile and minor traffic offenses regardless of disposition) all court documents the applicant can provide and include legible copies (for estimated dates select "est") (Completed by the applicant)

Date Violation or Charge Place(City/ST/ZIP) Court Type Disposition/Final Result 1 2

3

4

5

6

7

8

9

10

Drug Use History Instructions The applicant is the primary source of information about past or present drug use. Answer Yes/No to initial 7 questions. (If yes, to question 1 thru 6, complete section 2. If yes, to question 7, complete section 2 & 3) For estimated dates select "est" (Completed by the applicant)

Type of Drug Date of First Use Date of Last Use Nature/Frequency/Ingestion # of Uses

EST EST

EST EST

EST EST

Name Use:

Name Use Instructions Record your Entrance Name and any other names you may have gone by. Record must include "birth" name or "maiden" name for married females (select "EST" for Estimated date)

(Completed by the applicant) Reason (Must be Birth, Marriage, Decree, Maiden, Preference, or Other) you went by that name. Record the date that you first used the name and the date you last used the name.

First Last Middle Suffix Reason (see above) First Used Last Used

EST EST

EST EST

EST EST

U.S. Passport Information

1. Do you possess a U.S. passport (current or expired)?

US Passport Information

Date Issued: Expiration Date:

Passport Number:

Name Issued Under (First Last Middle):

Citizenship:

Select One: U.S citizen By Birth U.S citizen By Birth Abroad US Naturalized US Non- Citizen Res Alien 1. Do you now or have you EVER held dual/multiple citizenships? 2. Have you EVER been issued a passport (or identity card for travel) by a country other than the U.S.?

YES NO

YES NO

Residence History:

Residence History

Instructions List the places where you have lived, beginning with the most recent and working back 10 years. All periods must be accounted for in your list. Be sure to indicate the actual physical location of your residence. Do not use a post office box as an address. Do not list a permanent address when you were actually living at a school address, etc. Be sure to specify your location as closely as possible: For example Do not list only your base or ship. List your barracks number or home port. You may omit temporary military duty locations less than 90 days (list your permanent address instead), and you should use your APO/FPO address if you lived overseas. NOTE: For any address in the last 5 years, list a person who knew you at that address, and who preferably still lives in that area (do not list references for addresses completely outside the 5-year period, and do not list your spouse, former spouse, or other relatives). Provide Directions for addresses in the last 5 years if the address is General Delivery, a Rural or Star Route, or may be difficult to locate. (select "EST" for Estimated dates)

# From Date To Date City/Postal Code Street Address

1 EST Present

Resident Type (rent/own /military/other)

Name of Person who knew you (First Last, Mid, Suffix) Relationship (neighbor, landlord, friend, work assoc, other)

Date Last Contacted Phone # (or list Dont Know) Email (or list Dont Know)

EST

Street Address City/Postal Code


2 EST EST




EST



3 EST EST




EST



4 EST EST




EST


Education Record:

1.Have you attended any schools in the last 10 years? 2. Have you received a degree or diploma more than 10 years ago?

Education History

Instructions List the schools you have attended beyond Junior High School, beginning with the most recent and working back 7 years. List College or University degrees and the dates they were received. If all of your education occurred more than 7 years ago, list your most recent education beyond Junior High School no matter when that education occurred. For schools you attended in the past 3 years, list a person who knew you at the school (an instructor, student, etc.). Do not list people for education completely outside this 3-year period. For correspondence and extension classes provide the address where the records are maintained.

(Completed by the applicant)

# Name of School Postal Code/City State Country

1

Start Date End Date Graduated? (Y/N) Date DIPLOMA/DEGREE TYPE Major/Minor

EST EST

Title/Rank & Name of Person who knew you Postal

Code/City Street Address Cellular Phone #

(or list Dont Know) (First Last, Mid, Suffix)

Frequency of Contact Email (or list Dont Know)


2

Start Date End Date Graduated? (Y/N) Date If Yes, enter DEGREE TYPE Major/Minor

EST EST






3

Start Date End Date Graduated? (Y/N) Date If Yes, enter DEGREE TYPE Major/Minor

EST EST





YES NO

YES NO

Employment Record:

Employment History Instructions List your employment activities, beginning with the present (#1) and working back 7 years. You should list all full-time work, part-time work, self-employment, other paid work, and all periods of unemployment. The entire 7-year period must be accounted for without breaks, but you need not list employment before your 16th birthday. EXCEPTION: Show all federal civilian, whether it occurred in the last 7 years or not. See additional instructions for acceptable list of values for Employment Types and Termination Types. NOTE: DO NOT list your US Military Service employment history here (You will cover that in the next section). List the supervisor (verifier if for unemployment) for each period of employment.

(Completed by the applicant)

Check Type Civilian Government Foreign Unemployment

Military

# Name of Employer Street Address

1

City/Postal Code State Country Telephone Number Position Title

Is/was your physical work address different from address (Y / N - If Y provide work address provided above?) Street Address, City, St. ZIP Telephone Number

All Periods/This Employer Termination Type Termination Remarks (if negative) Part Time (Y/N)

Start Date EST End Date EST

Wage $ (per hour or month)

Title/Rank & Name of Person who knew you (1st Period). Postal Code/City Street Address (if different than above) Cellular Phone #

(or list Dont Know)

(First Last, M. Suffix)

Email (or list Dont Know)


Military


2







(or list Dont Know)




Military


3







(or list Dont Know)




Military


4







(or list Dont Know)



2. Do you have former federal civilian employment, excluding military service, NOT indicated previously, to report? 3. Have any of the following happened to you in the last seven (7) years at employment activities that you have not previously listed? (If 'Yes', you will be required to add an additional employment in Section 13A.) - Fired from a job? - Quit a job after being told you would be fired? - Have you left a job by mutual agreement following charges or allegations of misconduct? - Left a job by mutual agreement following notice of unsatisfactory performance? - Received a written warning, been officially reprimanded, suspended, or disciplined for misconduct

in the workplace, such as violation of a security policy?

YES NO

YES NO

Selective Service Record:

1. Were you born a male after December 31, 1959?

2. Have you registered with the Selective Service System (SSS)?

SSS#:

Military History:

1. Have you EVER served in the U.S. Military? 2. In the last 7 years, have you been subject to court martial or other disciplinary procedure under the Uniform Code of Military Justice (UCMJ), such as Article 15, Captain's mast, Article 135 Court of Inquiry, etc.? 3. Have you EVER served, as a civilian or military member in a foreign country's military, intelligence, diplomatic, security forces, militia, other defense force, or government agency?

If served, complete the following for EACH instance of service

From Date EST Last Duty Station for this Period:

To Date EST Branch of Service:

Officer

Current Status:

Enlisted Type of Service (Reserve/Guard/Active Duty):

Not Applicable State of Service: Service Number:

Type of Discharge: Assignment From To Duty Title

Date of Discharge:

If served, complete the following for EACH instance of service

From Date EST Last Duty Station for this Period:

To Date EST Branch of Service:

Officer

Current Status:

Enlisted Type of Service (Reserve/Guard/Active Duty):

Not Applicable State of Service: Service Number:

Type of Discharge: Assignment From To Duty Title

Date of Discharge:

YES NO

YES NO

YES NO

YES NO

YES NO

Personal References

Instructions List three people who know you well and live in the United States. They should be good friends, peers, colleagues, college roommates, etc., whose combined association with you covers as much as possible the last 10 years. Do

not list spouse, former spouse, or other relatives, and try not to list anyone who is listed elsewhere on this form.

Full Name(First Last, M. Suffix)

Friend

Neighbor From Date EST (must cover 10 years) School Mate To Date EST

Work Associate Street Address:

Other Postal Code/City/State

Cellular Number (or "don't know)

Email (or "don't

know)


Friend



Other Postal Code/City/State

Cellular Number (or "don't know)

Email (or "don't

know)


Friend



Other Postal Code/City/State Cellular Number (or

"don't know)

Email (or "don't

know)

Marital Status: Single Married to civilian Married to Military Divorced Separated Widowed Relatives&Associates Instructions:Providedetailsforallimmediatefamily.Mother,Father,Spouse,Children,Siblingsareallmandatory.ForEstimateddates,select"EST"

Spouse's Information Full Name (First Last, M. Suffix): Is this person a foreign relative? (Y/N) Place of Birth (city/st):

SSN: Is person Deceased? (Y/N) US Citizen: (Y/N)

DoB (or list "dont know" EST Should person be notified in case of emergency? (Y/N)

Known From Date EST Is this a Dependent? (Y/N) Do you have legal and/or physical custody? (Y/N) Known to Date EST Capable of self-care? (Y/N)

Marriage Date: EST Separation Date if applicable:

Maiden Name Marriage Certificate Date Issued:

Court of Record:

Contact Data Same As Applicant

Zip Code: Street Address:

Cellular Phone: Email:

If not born in the US, complete the following: INS Registration #: Date Issued: Exp. Date: City, State Issued: Court of Record

Biological Mother's Information

Full Name (First Last, M. Suffix): Is this person a foreign relative? (Y/N) Place of Birth (city/st):

Is person Deceased? (Y/N) US Citizen: (Y/N)






If not born in the US, complete the following:

INS Registration #: Date Issued: Exp. Date:

City, State Issued: Court of Record

Biological Father's Information Full Name (First Last, M. Suffix):

Is this person a foreign relative? (Y/N) Place of Birth (city/st): Is person Deceased? (Y/N) US Citizen: (Y/N)









Other Family Information Step-Father Step-Mother Foster Parent In law Child











Other Family Information Step-Father Step-Mother Foster Parent In law Child

Full Name: Is this person a foreign relative? (Y/N) Place of Birth (city/st):










Sibling's Information Brother Sister Step-Brother Step-Sister Half-Brother Half-Sister











Foreign Contact: 1. Do you have, or have you had, close and/or continuing contact with a foreign national within the last seven (7) years with whom you, or your spouse, or cohabitant are bound by affection, influence, common interests, and/or obligation? Include associates as well as relatives, not previously listed in Section 18.

Foreign Activities: 1. 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 they have direct control or direct ownership? (Exclude financial interests in companies or diversified mutual funds that are publicly traded on a U.S. exchange.) 2. Have you, your spouse, cohabitant, or dependent children EVER had any foreign financial interests that someone controlled on your behalf? 3. 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? 4. Do you, your spouse, cohabitant, or dependent children receive any additional benefits from a foreign country? 5. Have you additionally provided financial support for any foreign national?

Foreign Business, Professional Activities, and Foreign Government Contacts: 1. 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.) 2. 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.) 3. 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? 4. Have you in the past seven (7) years been involved in any other type of business venture with a foreign national not described above (own, co-own, serve as business consultant, provide financial support, etc.)? 5. 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.) 6. Have you or any member of your immediate family in the past seven (7) years had any contact with a foreign government, its Establishment (such as embassy, consulate, agency, military service, intelligence or security service, etc.) or its representatives, whether inside or outside the U.S.? (Answer 'No' if the contact was for routine visa applications and border crossings related to either official U.S. Government travel or foreign travel on a U.S. passport.)

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

7. Have you in the past seven (7) years sponsored any additional foreign national to come to the U.S. as a student, for work, or for permanent residence? 8. Have you EVER held political office in a foreign country? 9. Have you EVER voted in the election of a foreign country?

Foreign Travel: 1. Have you traveled outside the U.S. in the last seven (7) years?

Country # of Day Start Date End Date

PURPOSE (business/leisure/ education/tourism)

- While traveling to, or in this country, were you questioned, searched, or otherwise detained

(other than for normal customs requirements) by the local customs or security service officials when entering or leaving this country?

- While traveling to or in this country, were you involved in any encounter with the police? - While traveling to or in this country, were you contacted by, or in contact with any person

known or suspected of being involved or associated with foreign intelligence, terrorist, security, or military organizations?

- While traveling to, or in this country, were you involved in any counterintelligence or security - issues not reported? - While traveling to or in this country, were you contacted by, or in contact with anyone

exhibiting excessive knowledge of or undue interest in you or your job? - While traveling to or in this country, were you contacted by, or in contact with anyone

attempting to obtain classified information or unclassified, sensitive information? - While traveling to, or in this country, were you threatened, coerced, or pressured in any way

to cooperate with a foreign government official or foreign intelligence or security service? 2. Has your travel in the last seven (7) years been solely for U.S. Government business (i.e., no personal trips in conjunction with the official U.S. Government business)?

Psychological and Emotional Health: 1. 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 counseling was for any of the following reasons and was not court-ordered:

Strictly marital, family, grief not related to violence by you; or Strictly related to adjustments from service in a military combat environment. Please respond to this question with the following additional instruction: Victims of sexual

assault who have consulted with the health care professional regarding an emotional or mental health condition during this period strictly in relation to the sexual assault are instructed to answer NO.

2. Has a court or administrative agency EVER declared you mentally incompetent?

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

Police Record: 1. 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, or ticket to appear in court in a criminal proceeding against you? (Do not check if all the citations involved traffic infractions where the fine was less than $300 and did not include alcohol or drugs)

- Have you been arrested by any police officer, sheriff, marshal or any other type of law enforcement official?

- Have you been charged, convicted, or sentenced of a crime in any court? (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).

- Have you been or are you currently on probation or parole? - Are you currently on trial or awaiting a trial on criminal charges?

2. 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 to imprisonment for a term exceeding 1 year for that crime, and incarcerated as a result of that sentence for not less than 1 year? (Include all qualifying convictions in Federal, state, local, or military court, even if previously listed on this form)

- Have you EVER been charged with any felony offense? (Include those under the Uniform - Code of Military Justice and non-military/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?

3. Is there currently a domestic violence protective order or restraining order issued against you?

Illegal Use of Drug or Activity: 1. In the last seven (7) years, have you illegally used any drugs or controlled substances? Use of a drug or controlled substance includes injecting, snorting, inhaling, swallowing, experimenting with or otherwise consuming any drug or controlled substance. 2. 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 controlled substance? 3. Have you EVER illegally used or otherwise been involved with a drug or controlled substance while possessing a security clearance other than previously listed? 4. 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 and immediately affecting the public safety other than previously listed? 5. In the last seven (7) years have you intentionally engaged in the misuse of prescription drugs, regardless of whether or not the drugs were prescribed for you or someone else? 6. Have you EVER been ordered, advised, or asked to seek counseling or treatment as a result of your illegal use of drugs or controlled substances? 7. Have you EVER voluntarily sought counseling or treatment as a result of your use of a drug or controlled substance?

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

Use Of Alcohol: 1. 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 by law enforcement/public safety personnel?

2. Have you EVER been ordered, advised, or asked to seek counseling or treatment as a result of your use of alcohol? 3. Have you EVER voluntarily sought counseling or treatment as a result of your use of alcohol? 4. Have you EVER received counseling or treatment as a result of your use of alcohol in addition to what you have already listed on this form?

Investigation Clearance Record: 1. Has the U.S. Government (or a foreign government) EVER investigated your background and/or granted you a security clearance eligibility/access? 2. Have you EVER had a security clearance eligibility/access authorization denied, suspended, or revoked? (Note: An administrative downgrade or administrative termination of a security clearance is not a revocation.) 3. Have you EVER been debarred from government employment?

Financial Record:

1. Have you EVER experienced financial problems due to gambling?

2. In the past seven (7) years have you failed to file or pay Federal, state, or other taxes when required by law or ordinance?

3. In the past seven (7) years have you failed to file or pay Federal, state, or other taxes when required by law or ordinance?

4. Are you currently utilizing, or seeking assistance from, a credit counseling service or similar resource to resolve your financial difficulties? 5. 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 support payments. You had a judgment entered against you. (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor). 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 you are the sole debtor, as well as those for which you are a cosigner or guarantor).

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

6. Other than previously listed, have any of the following happened: In the past seven (7) years, - You had any possessions or property voluntarily or involuntarily repossessed or foreclosed?

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

- You defaulted on any type of loan? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor)

- You had bills or debts turned over to a collection agency? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor)

- You had any account or credit card suspended, charged off, or cancelled for failing to pay as agreed? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor)

- You were evicted for non-payment? - You had your wages, benefits, or assets garnished or attached for any reason? - You have been over 120 days delinquent on any debt not previously entered? (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 over 120 days delinquent on any debt? (Include financial obligations for which you are the sole debtor, as well as those for which you are a cosigner or guarantor)

Use of Information Technology Systems:

1. In the last seven (7) years have you illegally or without proper authorization accessed or attempted to access any information technology system?

2. In the last seven (7) years, have you illegally or without authorization, modified, destroyed, manipulated, or denied others access to information residing on an information technology system or attempted any of the above?

3. In the last seven (7) years, have you introduced, removed, or used hardware, software, or media in connection with any information technology system without authorization, when specifically prohibited by rules, procedures, guidelines, or regulations or attempted any of the above?

Non-Criminal Court Actions:

1. In the last ten (10) years, have you been a party to any public record civil court action not listed elsewhere on this form?

YES NO

YES NO

YES NO

YES NO

YES NO

Association Record: 1. Are you now or have you EVER been a member of an organization dedicated to terrorism, either with an awareness of the organization's dedication to that end, or with the specific intent to further such activities?

2. Have you EVER knowingly engaged in any acts of terrorism?

3. Have you EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government by force?

4. 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 awareness of the organization's dedication to that end or with the specific intent to further such activities? 5. 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 awareness of the organization's dedication to that end or with the specific intent to further such activities? 6. Have you EVER knowingly engaged in activities designed to overthrow the U.S. Government by force? 7. Have you EVER associated with anyone involved in activities to further terrorism? OTHER REMARKS:

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

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you First Last Mid Suffix: Street AddressTitleRank Name of Person who knew you First Last Mid Suffix: Cellular Phone or list Dont KnowTitleRank Name of Person who knew you First Last Mid Suffix: TitleRank Name of Person who knew you First Last Mid SuffixRow1: Frequency of ContactRow1: Email or list Dont KnowRow1: Name of School2: Postal CodeCity2: State2: Country2: Start DateRow1_3: Start DateRow1_4: End DateEST_3: End DateEST_4: Graduated YNEST_2: DateEST_2: If Yes enter DEGREE TYPEEST: MajorMinorEST_2: Postal CodeCityTitleRank Name of Person who knew you First Last Mid Suffix_2: Street AddressTitleRank Name of Person who knew you First Last Mid Suffix_2: Cellular Phone or list Dont KnowTitleRank Name of Person who knew you First Last Mid Suffix_2: TitleRank Name of Person who knew you First Last Mid SuffixRow1_2: Frequency of ContactRow1_2: Email or list Dont KnowRow1_2: Name of School3: Postal CodeCity3: State3: Country3: Start DateRow1_5: Start DateRow1_6: End DateEST_5: End DateEST_6: Graduated YNEST_3: DateEST_3: If Yes enter DEGREE TYPEEST_2: MajorMinorEST_3: Postal CodeCityTitleRank Name of Person who knew you First Last Mid Suffix_3: Street AddressTitleRank Name of Person who knew you First Last Mid Suffix_3: Cellular Phone or list Dont KnowTitleRank Name of Person who knew you First Last Mid Suffix_3: TitleRank Name of Person who knew you First Last Mid SuffixRow1_3: Frequency of ContactRow1_3: Email or list Dont KnowRow1_3: Check Type: Civilian: Government: Foreign: Check TypeRow1: Completed by the applicantRow2: Military: Name of Employer1: Street Address1: CityPostal CodeRow1_5: StateRow1: CountryRow1: Telephone NumberRow1: Position TitleRow1: Iswas your physical work address different from address Y N If Y provide work address provided aboveRow1: Street Address City St ZIPRow1: Telephone NumberRow1_2: Start DateRow1_7: ESTRow1: End DateRow1: ESTRow1_2: Termination TypeRow1: Termination Remarks if negativeRow1: Start DateRow2: ESTRow2: End DateRow2: ESTRow2_2: Termination TypeRow2: Termination Remarks if negativeRow2: Wage per hour or month: Postal CodeCityTitleRank Name of Person who knew you 1st Period First Last M Suffix: Street Address if different than aboveTitleRank Name of Person who knew you 1st Period First Last M Suffix: Cellular Phone or list Dont KnowTitleRank Name of Person who knew you 1st Period First Last M Suffix: TitleRank Name of Person who knew you 1st Period First Last M SuffixRow1: Email or list Dont Know: Check Type_2: Civilian_2: Government_2: Foreign_2: Check TypeRow1_2: TitleRank Name of Person who knew you 1st Period First Last M SuffixRow3: Military_2: Name of Employer2: Street Address2: CityPostal CodeRow1_6: StateRow1_2: CountryRow1_2: Telephone NumberRow1_3: Position TitleRow1_2: Iswas your physical work address different from address Y N If Y provide work address provided aboveRow1_2: Street Address City St ZIPRow1_2: Telephone NumberRow1_4: Start DateRow1_8: ESTRow1_3: End DateRow1_2: ESTRow1_4: Termination TypeRow1_2: Termination Remarks if negativeRow1_2: Start DateRow2_2: ESTRow2_3: End DateRow2_2: ESTRow2_4: Termination TypeRow2_2: Termination Remarks if negativeRow2_2: Wage per hour or month_2: Postal CodeCityTitleRank Name of Person who knew you 1st Period First Last M Suffix_2: Street Address if different than aboveTitleRank Name of Person who knew you 1st Period First Last M Suffix_2: Cellular Phone or list Dont KnowTitleRank Name of Person who knew you 1st Period First Last M Suffix_2: TitleRank Name of Person who knew you 1st Period First Last M SuffixRow1_2: Email or list Dont Know_2: Civilian_3: Government_3: Foreign_3: Check TypeRow1_3: Military_3: Name of Employer3: Street Address3: CityPostal CodeRow1_7: StateRow1_3: CountryRow1_3: Telephone NumberRow1_5: Position TitleRow1_3: Iswas your physical work address different from address Y N If Y provide work address provided aboveRow1_3: Street Address City St ZIPRow1_3: Telephone NumberRow1_6: Start DateRow1_9: ESTRow1_5: End DateRow1_3: ESTRow1_6: Termination TypeRow1_3: Termination Remarks if negativeRow1_3: Start DateRow2_3: ESTRow2_5: End DateRow2_3: ESTRow2_6: Termination TypeRow2_3: Termination Remarks if negativeRow2_3: Wage per hour or month_3: Postal CodeCityTitleRank Name of Person who knew you 1st Period First Last M Suffix_3: Street Address if different than aboveTitleRank Name of Person who knew you 1st Period First Last M Suffix_3: Cellular Phone or list Dont KnowTitleRank Name of Person who knew you 1st Period First Last M Suffix_3: TitleRank Name of Person who knew you 1st Period First Last M SuffixRow1_3: Email or list Dont Know_3: Check Type_4: Civilian_4: Government_4: Foreign_4: Check TypeRow1_4: TitleRank Name of Person who knew you 1st Period First Last M SuffixRow3_2: Military_4: Name of Employer4: Street Address4: CityPostal CodeRow1_8: StateRow1_4: CountryRow1_4: Telephone NumberRow1_7: Position TitleRow1_4: Iswas your physical work address different from address Y N If Y provide work address provided aboveRow1_4: Street Address City St ZIPRow1_4: Telephone NumberRow1_8: Start DateRow1_10: ESTRow1_7: End DateRow1_4: ESTRow1_8: Termination TypeRow1_4: Termination Remarks if negativeRow1_4: Start DateRow2_4: ESTRow2_7: End DateRow2_4: ESTRow2_8: Termination TypeRow2_4: Termination Remarks if negativeRow2_4: Wage per hour or month_4: Postal CodeCityTitleRank Name of Person who knew you 1st Period First Last M Suffix_4: Street Address if different than aboveTitleRank Name of Person who knew you 1st Period First Last M Suffix_4: Cellular Phone or list Dont KnowTitleRank Name of Person who knew you 1st Period First Last M Suffix_4: TitleRank Name of Person who knew you 1st Period First Last M SuffixRow1_4: Email or list Dont Know_4: YES_5: NO_5: YES_6: NO_6: YES_7: NO_7: YES_8: NO_8: YES_9: NO_9: YES_10: NO_10: YES_11: NO_11: EST_4: EST_5: Last Duty Station for this Period: EST_6: EST_7: Branch of Service: Officer: Current Status: Enlisted: Type of Service ReserveGuardActive Duty: Not Applicable: State of Service: Service Number: Type of Discharge: Date of Discharge: AssignmentDate of Discharge: FromDate of Discharge: ToDate of Discharge: Duty TitleDate of Discharge: AssignmentRow2: FromRow2: ToRow2: Duty TitleRow2: AssignmentRow3: FromRow3: ToRow3: Duty TitleRow3: EST_8: EST_9: Last Duty Station for this Period_2: EST_10: EST_11: Branch of Service_2: Officer_2: Current Status_2: Enlisted_2: Type of Service ReserveGuardActive Duty_2: Not Applicable_2: State of Service_2: Service Number_2: Type of Discharge_2: Date of Discharge_2: AssignmentDate of Discharge_2: FromDate of Discharge_2: ToDate of Discharge_2: Duty TitleDate of Discharge_2: AssignmentRow2_2: FromRow2_2: ToRow2_2: Duty TitleRow2_2: AssignmentRow3_2: FromRow3_2: ToRow3_2: Duty TitleRow3_2: Full NameFirst Last M SuffixFriend Neighbor School Mate Work Associate Other: From Date: EST_12: To Date: EST_13: Street Address: Postal CodeCityState: Cellular Number or dont know: Email or dont know: Full NameFirst Last M SuffixFriend Neighbor School Mate Work Associate Other_2: From Date_2: EST_14: To Date_2: EST_15: Street Address_2: Postal CodeCityState_2: Cellular Number or dont know_2: Email or dont know_2: Full NameFirst Last M SuffixFriend Neighbor School Mate Work Associate Other_3: From Date_3: EST_16: To Date_3: EST_17: Street Address_3: Postal CodeCityState_3: Cellular Number or dont know_3: Email or dont know_3: Married to civilian: Married to Military: Divorced: Separated: Widowed: Full Name First Last M Suffix: Is this person a foreign relative YN: Place of Birth cityst: Is person Deceased YN: US Citizen YN: DoB or list dont know: Should person be notified in case of emergency YN: Known From Date: Is this a Dependent YN: Do you have legal andor physical custody YN: Known to Date: EST_18: Capable of selfcare YN: Marriage Date: Separation Date if applicable: Maiden Name: Marriage Certificate Date Issued: Court of Record: Zip Code: Street Address_4: Cellular Phone: Email: INS Registration: Date Issued_2: Exp Date: City State Issued: Court of Record_2: Full Name First Last M Suffix_2: Is this person a foreign relative YN_2: Place of Birth cityst_2: Is person Deceased YN_2: US Citizen YN_2: DoB or list dont know_2: Should person be notified in case of emergency YN_2: Known From Date_2: Is this a Dependent YN_2: Do you have legal andor physical custody YN_2: Known to Date_2: Capable of selfcare YN_2: Zip Code_2: Street Address_5: Cellular Phone_2: Email_2: INS Registration_2: Date Issued_3: Exp Date_2: City State Issued_2: Court of Record_3: Full Name First Last M Suffix_3: Is this person a foreign relative YN_3: Place of Birth cityst_3: Is person Deceased YN_3: US Citizen YN_3: DoB or list dont know_3: Should person be notified in case of emergency YN_3: Known From Date_3: Is this a Dependent YN_3: Do you have legal andor physical custody YN_3: Known to Date_3: Capable of selfcare YN_3: Zip Code_3: Street Address_6: Cellular Phone_3: Email_3: INS Registration_3: Date Issued_4: Exp Date_3: City State Issued_3: Court of Record_4: Other Family Information StepFather StepMother Foster Parent In law ChildRow1: Is this person a foreign relative YN_4: Is person Deceased YN_4: US Citizen YN_4: DoB or list dont know_4: Should person be notified in case of emergency YN_4: Known From Date_4: Is this a Dependent YN_4: Do you have legal andor physical custody YN_4: Known to Date_4: Capable of selfcare YN_4: Zip Code_4: Street Address_7: Cellular Phone_4: Email_4: INS Registration_4: Date Issued_5: Exp Date_4: City State Issued_4: Court of Record_5: Other Family Information StepFather StepMother Foster Parent In law ChildRow1_2: Is this person a foreign relative YN_5: Is person Deceased YN_5: US Citizen YN_5: DoB or list dont know_5: Should person be notified in case of emergency YN_5: Known From Date_5: Is this a Dependent YN_5: Do you have legal andor physical custody YN_5: Known to Date_5: Capable of selfcare YN_5: Zip Code_5: Street Address_8: Cellular Phone_5: Email_5: INS Registration_5: Date Issued_6: Exp Date_5: City State Issued_5: Court of Record_6: Is this person a foreign relative YN_6: Is person Deceased YN_6: US Citizen YN_6: DoB or list dont know_6: Should person be notified in case of emergency YN_6: Known From Date_6: Is this a Dependent YN_6: Do you have legal andor physical custody YN_6: Known to Date_6: Capable of selfcare YN_6: Zip Code_6: Street Address_9: Cellular Phone_6: Email_6: INS Registration_6: Date Issued_7: Exp Date_6: City State Issued_6: Court of Record_7: Siblings Information Brother Sister StepBrother StepSister HalfBrother HalfSisterRow1: Is this person a foreign relative YN_7: Is person Deceased YN_7: US Citizen YN_7: DoB or list dont know_7: Should person be notified in case of emergency YN_7: Known From Date_7: Is this a Dependent YN_7: Do you have legal andor physical custody YN_7: Known to Date_7: Capable of selfcare YN_7: Zip Code_7: Street Address_10: Cellular Phone_7: Email_7: INS Registration_7: Date Issued_8: Exp Date_7: City State Issued_7: Court of Record_8: Siblings Information Brother Sister StepBrother StepSister HalfBrother HalfSisterRow1_2: Is this person a foreign relative YN_8: Is person Deceased YN_8: US Citizen YN_8: DoB or list dont know_8: Should person be notified in case of emergency YN_8: Known From Date_8: Is this a Dependent YN_8: Do you have legal andor physical custody YN_8: Known to Date_8: Capable of selfcare YN_8: Zip Code_8: Street Address_11: Cellular Phone_8: Email_8: INS Registration_8: Date Issued_9: Exp Date_8: City State Issued_8: Court of Record_9: Siblings Information Brother Sister StepBrother StepSister HalfBrother HalfSisterRow1_3: Is this person a foreign relative YN_9: Is person Deceased YN_9: US Citizen YN_9: DoB or list dont know_9: Should person be notified in case of emergency YN_9: Known From Date_9: Is this a Dependent YN_9: Do you have legal andor physical custody YN_9: Known to Date_9: Capable of selfcare YN_9: Zip Code_9: Street Address_12: Cellular Phone_9: Email_9: INS Registration_9: Date Issued_10: Exp Date_9: City State Issued_9: Court of Record_10: YES_12: NO_12: YES_13: NO_13: YES_14: NO_14: YES_15: NO_15: YES_16: NO_16: YES_17: NO_17: YES_18: NO_18: YES_19: NO_19: YES_20: NO_20: YES_21: NO_21: YES_22: NO_22: YES_23: NO_23: YES_24: NO_24: YES_25: NO_25: YES_26: NO_26: CountryRow1_5: of DayRow1: Start DateRow1_11: End DateRow1_5: PURPOSE businessleisure educationtourismRow1: CountryRow2: of DayRow2: Start DateRow2_5: End DateRow2_5: PURPOSE businessleisure educationtourismRow2: CountryRow3: of DayRow3: Start DateRow3: End DateRow3: PURPOSE businessleisure educationtourismRow3: CountryRow4: of DayRow4: Start DateRow4: End DateRow4: PURPOSE businessleisure educationtourismRow4: CountryRow5: of DayRow5: Start DateRow5: End DateRow5: PURPOSE businessleisure educationtourismRow5: YES_27: NO_27: YES_28: NO_28: YES_29: NO_29: YES_30: NO_30: YES_31: NO_31: YES_32: NO_32: YES_33: NO_33: YES_34: NO_34: YES_35: NO_35: YES_36: NO_36: YES_37: NO_37: YES_38: NO_38: YES_39: NO_39: YES_40: NO_40: YES_41: NO_41: YES_42: NO_42: YES_43: NO_43: YES_44: NO_44: YES_45: NO_45: YES_46: NO_46: YES_47: NO_47: YES_48: NO_48: YES_49: NO_49: YES_50: NO_50: YES_51: NO_51: YES_52: NO_52: YES_53: NO_53: YES_54: NO_54: YES_55: NO_55: YES_56: NO_56: YES_57: NO_57: YES_58: NO_58: YES_59: NO_59: YES_60: NO_60: YES_61: NO_61: YES_62: NO_62: YES_63: NO_63: YES_64: NO_64: Check Type_3:

Single: Same As App1: Same As App2: Same As App: Same As App3: Same As App9: Sib2_1: Sib2_2: Sib2_3: Sib2_4: Sib2_5: Sib2_6: Sib1_7: Sib1_8: Sib1_9: Sib1_10: Sib1_11: Sib1_12: Sib1: Sib2: Sib3: Sib4: Sib5: Sib6: Sib1_1: Sib1_2: Sib1_3: Sib1_4: Sib1_5: Sib1_6: SF1: sm1: FOSTER1: inlaw1: child1: SF2: sm2: FOSTER2: inlaw2: child2: Same As App4: Same As App5: Same As App6: Same As App7: Text9: Recruiter: Text10253: Date1 2 3 4 5 6 7 8 9 10: Violation or Charge1 2 3 4 5 6 7 8 9 10: PlaceCitySTZIP1 2 3 4 5 6 7 8 9 10: PlaceCitySTZIP1 2 3 4 5 6 7 8 9 10_2: PlaceCitySTZIP1 2 3 4 5 6 7 8 9 10_3: Court Type1 2 3 4 5 6 7 8 9 10: DispositionFinal Result1 2 3 4 5 6 7 8 9 10: Date1 2 3 4 5 6 7 8 9 10_2: Violation or Charge1 2 3 4 5 6 7 8 9 10_2: PlaceCitySTZIP1 2 3 4 5 6 7 8 9 10_4: PlaceCitySTZIP1 2 3 4 5 6 7 8 9 10_5: PlaceCitySTZIP1 2 3 4 5 6 7 8 9 10_6: Court Type1 2 3 4 5 6 7 8 9 10_2: DispositionFinal Result1 2 3 4 5 6 7 8 9 10_2: Date1 2 3 4 5 6 7 8 9 10_3: Violation or Charge1 2 3 4 5 6 7 8 9 10_3: PlaceCitySTZIP1 2 3 4 5 6 7 8 9 10_7: PlaceCitySTZIP1 2 3 4 5 6 7 8 9 10_8: PlaceCitySTZIP1 2 3 4 5 6 7 8 9 10_9: Court Type1 2 3 4 5 6 7 8 9 10_3: DispositionFinal Result1 2 3 4 5 6 7 8 9 10_3: Date1 2 3 4 5 6 7 8 9 10_4: Violation or Charge1 2 3 4 5 6 7 8 9 10_4: PlaceCitySTZIP1 2 3 4 5 6 7 8 9 10_10: PlaceCitySTZIP1 2 3 4 5 6 7 8 9 10_11: PlaceCitySTZIP1 2 3 4 5 6 7 8 9 10_12: Court Type1 2 3 4 5 6 7 8 9 10_4: DispositionFinal Result1 2 3 4 5 6 7 8 9 10_4: Date1 2 3 4 5 6 7 8 9 10_5: Violation or Charge1 2 3 4 5 6 7 8 9 10_5: PlaceCitySTZIP1 2 3 4 5 6 7 8 9 10_13: PlaceCitySTZIP1 2 3 4 5 6 7 8 9 10_14: PlaceCitySTZIP1 2 3 4 5 6 7 8 9 10_15: Court Type1 2 3 4 5 6 7 8 9 10_5: DispositionFinal Result1 2 3 4 5 6 7 8 9 10_5: Date1 2 3 4 5 6 7 8 9 10_6: Violation or Charge1 2 3 4 5 6 7 8 9 10_6: PlaceCitySTZIP1 2 3 4 5 6 7 8 9 10_16: PlaceCitySTZIP1 2 3 4 5 6 7 8 9 10_17: PlaceCitySTZIP1 2 3 4 5 6 7 8 9 10_18: Court Type1 2 3 4 5 6 7 8 9 10_6: DispositionFinal Result1 2 3 4 5 6 7 8 9 10_6: Date1 2 3 4 5 6 7 8 9 10_7: Violation or Charge1 2 3 4 5 6 7 8 9 10_7: PlaceCitySTZIP1 2 3 4 5 6 7 8 9 10_19: PlaceCitySTZIP1 2 3 4 5 6 7 8 9 10_20: PlaceCitySTZIP1 2 3 4 5 6 7 8 9 10_21: Court Type1 2 3 4 5 6 7 8 9 10_7: DispositionFinal Result1 2 3 4 5 6 7 8 9 10_7: Date1 2 3 4 5 6 7 8 9 10_8: Violation or Charge1 2 3 4 5 6 7 8 9 10_8: PlaceCitySTZIP1 2 3 4 5 6 7 8 9 10_22: PlaceCitySTZIP1 2 3 4 5 6 7 8 9 10_23: PlaceCitySTZIP1 2 3 4 5 6 7 8 9 10_24: Court Type1 2 3 4 5 6 7 8 9 10_8: DispositionFinal Result1 2 3 4 5 6 7 8 9 10_8: Date1 2 3 4 5 6 7 8 9 10_9: Violation or Charge1 2 3 4 5 6 7 8 9 10_9: PlaceCitySTZIP1 2 3 4 5 6 7 8 9 10_25: PlaceCitySTZIP1 2 3 4 5 6 7 8 9 10_26: PlaceCitySTZIP1 2 3 4 5 6 7 8 9 10_27: Court Type1 2 3 4 5 6 7 8 9 10_9: DispositionFinal Result1 2 3 4 5 6 7 8 9 10_9: Date1 2 3 4 5 6 7 8 9 10_10: Violation or Charge1 2 3 4 5 6 7 8 9 10_10: PlaceCitySTZIP1 2 3 4 5 6 7 8 9 10_28: PlaceCitySTZIP1 2 3 4 5 6 7 8 9 10_29: PlaceCitySTZIP1 2 3 4 5 6 7 8 9 10_30: Court Type1 2 3 4 5 6 7 8 9 10_10: DispositionFinal Result1 2 3 4 5 6 7 8 9 10_10: Type of DrugRow1: Date of First UseRow1: Date of Last UseEST: NatureFrequencyIngestionEST: of UsesEST: Type of DrugRow2: Date of First UseRow2: Date of Last UseEST_2: NatureFrequencyIngestionEST_2: of UsesEST_2: Type of DrugRow3: Date of First UseRow3: Date of Last UseEST_3: NatureFrequencyIngestionEST_3: of UsesEST_3: Program: Sub Prgm: Specialty: Privacy Act: Films: NVRA: 2644: 2645: DATE: SOURCE: Gender: SSN:

NAME: NAME2: DOB: Citzenship: Alien: Alien #: RACe: ETHNICITY: HAIR: EYE: Religion: Languages: HGT: WGT: SSS#:

COntact #: ADDRESS:

EMAIL: HOR ADDRESS:

DL #:

DL ST:

DL EXP DATE:

POB:

Additional Comments: CIT: YPRS: NCQ: NED: YMORALS: NDEP: NAGE: YDrug: NPHYs: YSSN Verified: YWaiver: NCivil Court: NPERPETUATED LEADS: Med HX: MED HX1: MEd Hx 2: Law: Law1: Law2: Drug1: Drug 2: Button1: Button2: Button3: Button4: Button5: Button6: Button7:

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