CLEAR FORM EXCEPT BASIC NAVY & RECRUITER …

1 CITY: STATE: ZIP: COUNTY/PARISH:Prior Military Service FROM:TO: PAYGRADE: RE-CODE: CLEAR form EXCEPT BASIC navy & RECRUITER INFO (p. 2)RESERVE RECRUITER TOOL BOX Updated (1130)In order to keep this Toolkit updated, please send all updates/additions/comments to toolkit creator: NC1 Marta Martin / 504-906-0303 (text)( ) / LAST, FIRST & INITIAL: FULL NAME:SOCIAL:DOB:ADDRESS:EMAIL: GET SELECTIVE SERVICE #NRD/NTAGPOB:DL STATE,#, EXP.: AGE: CLEAR ENTIRE form INITIAL CONTACT: INTERVIEW DATE: PROCESSING DATE: PHYSICAL DATE: CONTRACT DATE:REQUESTED RATE: a.

2 TEST IDb. TEST SCORESAFQTPERCENTILEGSARWKPCMKEIASMCAOVE PREVIOUS RATE:ASVAB SCORES NEEDED FOR REQUESTED RATE:RELIGION:ASVABPHONE NUMBER:Prior Military/Last Duty Station:Branch: MOS/Rate:Re-Code:RAD:End IRR:High School/College:Start Graduation Dates: City/State:# DEPENDENTS:ED. CODE:MARITAL STATUS:BRANCH:--MEDICALH eight:Weight:Body fat:TATTOOS:Current Medications:VA Claim?Medical Issues:SSN: Dependent?Spouse: Spouse DOB: Relationship: Address: Citizenship:Date Married:Additional information to be collected to make your job easier!PNOK:SNOK:Name, Relationship, Address, Phone #DOB:Dependent:DOB:Dependent:DOB:Depende nt:Child 1: Relationship: Address:Child 2: Relationship: Address:Child 3: Spouse Next of Kin: Relationship: Address:Relationship: Address:Other Person: Relationship:Address:Name, Relationship, Address, Phone #BENEFICIARY 100%Name: Address:ALLOTMENT 80%Name:Address:GRATUITY 100%Name: Address:MRWKHU V IXOO QDPH Address: FDWKHU V IXOO QDPH Address:Relationship: Relationship: Dependent ?

3 Dependent?STATE: ZIP CODE: RECRUITER NAME: RECRUITER 'S NUMBER: RECRUITER ADDRESS: CITY: NRD/NTAG: STATION: RSID:PAYGRADE: RECRUITER SOC:TITLE:Military?1966/1 Item 19. p. 310-Block 1: Number of enlistment - enter one digit code to indicate the number of enlistments in the navy as follows: 1 - 1st enlistment (USN/USNR) 2 - 2nd enlistment (USN/USNR) 3 - 3rd enlistment (USN/USNR) 4 - 4th enlistment (USN/USNR), Block 2: navy recruiting Region Code: navy Recruiting Region East- 1 navy Recruiting Region West -2 Block 3: Army Regional Recruiting Command (RRC).

4 P. 312-313 Block 4, 5: NRD 2-digit codeBlock 6, 7: MEPS 2-digit codeBlock 8, 9, 10: Leave BlankBlock 11, 12, 13, 14, 15, 16: YYMMDD date last dischargeBlock 17, 18: 2-digit code Last Discharged BranchBlock 19, 20: 2-digit Acquisition codeBlock 21, 22: Branch and class code USN 11, USNR 32 Block 23: Category of Enlistee CodeBlock 24, 25: 2-digit Place of BirthBlock 26, 27: Description of type of enlistmentBlock 28, 29: RE CodeBlocks 30-39: Foreign language (leave blank if none)Blocks 40-55: leave blankBlock 56: Type of DischargeBlock 57: "X"Block 58, 59: Block 60-65: BlankBlock 66-68: NAPT test score (000 if not taken)Block 69-70: Leave BlankBlock 71: Voluntary EnlistmentBlocks 72-140: Leave BlankPROGRAM DESCRIPTION:ENLISTING UNDER THE PROVISIONS OF THE NAVET ENLISTMENT PROGRAM IN THE PERMANENT RATE OS/E5 FOR A PERIOD OF 4 AND CONSENT FOR DISCLOSURE OR RECORDSFROM:ADDRESSEE.

5 (Authorizers Name)(Social Security Number)(Date of Birth)(Address)RELEASE INFORMATION TO PHONE #Fax #I hereby authorize and consent to the addressee, to disclose to navy recruiting personnel, the records in your possession concerning my education, employment, medical history, or other information as described below. In compliance with some State Statutes that require special permission to release otherwise privileged information., please release records pertaining to alcohol abuse or test results, drug abuse or test results, mental health, developmental disabilities, and sexually transmitted information to be disclosed:PURPOSE: I understand the purpose or need for this information is to provide navy recruiting personnel with pertinent information to determine my eligibility for enlistment in the United States NOTICE: Information disclosed pursuant to this authorization may be subject to redisclosure and no longer protected by of the HIPPA Act of 1996.

6 Information disclosed pursuant to this release will be protected in accordance with government regulations and is FOR OFFICIAL USE PERTAINING TO HEALTH CARE: Treatment, payment, enrollment or eligibility of benefits from a health care plan may not be conditioned on obtaining an individuals : This authorization and consent is subject to revocation at any time, EXCEPT to the extent that action has been taken in compliance herein. Revocation to be in writing to the addressee above. Authorization and consent for the specific disclosure of information expires on:Expiration Date:(Authorizer's Signature)DateIf the authorizer is not the individual listed at the top of this form , state the relationship to the individual:(Witness)Date"Copy of authorization is as valid as original"-- voter registration INFORMATION1.

7 If you are not registered to vote where you live now, would you like to apply to register to vote here today?(Xone)DYESIF YOU DO NOT MARK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME. Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency. If you would like help filling out the voter registration application form , we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private.

8 If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with: Federal Voting Assistance Program 1155 Defense Pentagon Washington, DC 20301-1155 Telephone Number: 800-438-VOTE .. If you decline to register to vote, that information will remain confidential and will only be used for voter registration purposes. If you register to vote, information regarding the office in which the application was submitted will remain confidential and only be used for voter registration purposes.

9 2. PRINTED NAME3. SIGNATUREDD form 2645, NOV 2008 PREVIOUS EDITION IS OBSOLETE. 4. DATE(YYYYMMDD)Adobe Professlonal RESTRICTIONS ON PERSONAL CONDUCT IN THE ARMED FORCES(For use of this form , see USMEPCOM Reg 601-23)a. A member may be separated for a pattern of disciplinary infractions, a pattern of misconduct, commission of a seriousoffense, or civilian A member who has been referred to a rehabilitation program for personal drug and alcohol abuse may be separatedfor failure through inability or refusal to participate in, cooperate in, or successfully complete such a A member may be discharged by reason of parenthood if it is determined the member, because of parentalresponsibilities.

10 Is unable to perform his or her duties satisfactorily or is unavailable for worldwide assignment member may be separated for failure to meet Service weight control member may be separated for harassment or violence against any Service form 601-23-4-E, SEP 2011 Replaces USMEPCOM form 601-23-4-E dated FEB 1998, which is obsolete1. Military life is fundamentally different from civilian life. The military has its own laws, rules, customs, and traditions,including numerous restrictions on personal behavior, that would not be acceptable in civilian society.