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. 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?

2 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 ?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).

3 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:(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.

4 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. 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.

5 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. 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. 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.

6 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. 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, 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.

7 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. These are necessarybecause military units and personnel must maintain the high standards of morale, good order and discipline, and unitcohesion that are essential for combat The Armed Forces must be ready at all times for worldwide deployment. Military law and regulations, including theUniform Code of Military Justice, apply to Service members at all times, both on base or off base, from the time themember enters the Service until the member is discharged or otherwise separated from the Armed Members of the Armed Forces may be involuntarily separated before their term of service ends for various reasonsestablished by law and military regulations, such as:X_____REQUEST FOR CONDITIONAL RELEASE(Read Privacy Act Statement and Instructions on back before completing this form .)

8 SECTION I - REQUEST FOR RELEASE1. SERVICE MEMBER DATA2. RECRUITING OFFICE ADDRESSa. NAME (Last, First, Middle Initial)b. PAY GRADEd. SERVICE COMPONENTc. SSN or EDIPI3. ACKNOWLEDGEMENT OF SERVICE MEMBERa. I request a conditional release to process for entrance into another component of the Military Service. If I am a member of the National Guard orReserve, I understand that I must attend all scheduled training until such time as I am enlisted or appointed into another Service. I also understand thatI am to keep my current commander informed of any change in my OFFICER MEMBER ONLY. I hereby tender my resignation from thed. MEMBER SIGNATUREe. DATE SIGNED4. RECRUITER REQUEST FOR CONDITIONAL RELEASEa. Request conditional release to enlist/appoint member into theb. NAME OF RECRUITER (Last, First, Middle Initial)e. TITLEc. SIGNATUREd. DATE SIGNEDSECTION II - APPROVAL/DISAPPROVAL5.(X as applicable)a. APPROVED. Individual is recommended and conditional release is granted.

9 The release is valid AUTHORIZING OFFICIALa. NAME (Last, First, Middle Initial)b. TITLEe. SIGNATUREf. DATE member was administered the oath of enlistment or appointment intoTHIS form AND A COPY OF THE OATH MUST BE RETURNED TO THE ADDRESS IN ITEM TO EFFECT THE MEMBER'S DISCHARGEOR WITHDRAWAL OF FEDERAL CERTIFYING OFFICIALa. NAME (Last, First, Middle Initial)b. TITLEf. SIGNATUREg. DATE SIGNEDc. UNIT/COMMANDSECTION III - NOTIFICATION OF ENLISTMENT/APPOINTMENT ACTIONDD form 368, AUG 2011 PREVIOUS EDITION IS CURRENT UNIT/COMMAND(current component); request that it be acceptedcontingent upon actual appointment or enlistment in the(requesting component), and be effective the day preceding thedate of my acceptance of appointment or TELEPHONE NUMBER(Include area code).b. DISAPPROVED. Release is not granted. (Explain in "Remarks.")d. ADDRESSc. TELEPHONE NUMBER(Include area code)c. ENLISTED MEMBER ONLY. I understand I will be discharged from my current status effective the day preceding the date of my enlistment orappointment.

10 (1) STREET(2) CITY(3) STATE(4) ZIP CODEa. STREETb. CITYc. STATEd. ZIP CODE(Service/Component).(1) STREET(2) CITY(3) STATE(4) ZIP CODEe. ADDRESS(1) STREET(2) CITY(3) STATE(4) ZIP CODEf. ADDRESSA dobe Professional IV - REMARKSPRIVACY ACT STATEMENTAUTHORITY: 10 Sections 261, 516, 651, 716, 3013, 5013, 8013, 12104, 12105, 12106, 12107, 12208, 12213, 12214, and 12645; 32 323; and DoD Instruction , Transfer of Service Members Between Reserve and Regular Components of the Military PURPOSE(S): To document coordination and concurrence of one Military Service for discharge and accession to another USE(S): : Voluntary; however, failure to furnish all requested information may result in delay or denial of release from current Military INSTRUCTIONS. When this form is not computer generated, use typewriter or dark ink for all entries. Enter all dates in YYMMDD format. Use full street address,city, state and ZIP code for addresses.