PRIVACY ACT STATEMENT ROUTINE USES: …

1 HANDWRITTEN STATEMENT Print Form Honor - Courage - Commitment PRIVACY ACT STATEMENT . AUTHORITY AND PURPOSE: 5 301, Departmental Regulations; and 9397 (SSN). Provided information is used to assist officials and employees of the Navy in the management, supervision and administration of Navy personnel (officer and enlisted) and the operations of related personnel affairs and functions. ROUTINE USES: Information will be utilized by Department of the Navy officials in verifying qualifications and suitability for enlistment. DISCLOSURE: Disclosure is voluntary; however, failure to provide the requested information as well as the social security number may result in denial of enlistment into the United States Navy.

2 Event of Offense Charge if Cited City State Name(s) of Police Agency(s) In the Court of Place of Residence at the Time of Offense City State Date of the Offense/Charge Age of Applicant at the Time of Offense/Charge Outcome, Disposition if Charged and Final Status Description : Who, What, Where, When, How I, (Name) (SSN) do honestly declare that: Honor, Courage, Commitment: I affirm that the above STATEMENT is true in all respects. Applicants Signature Date Witness' Signature Date NAVCRUIT 1133/78 (Rev 2-09) FOR OFFICIAL USE ONLY WHEN FILLED IN.