PROCESSING KIT CREATED BY NCC (SW) MIKE HARSHBARGER …

1 RESET form PROCESSING KIT CREATED BY NCC (SW) MIKE HARSHBARGER VER - RELEASE APR 18. NRD / NRS / RECRUITER INFORMATION. DATE KIT SIGNED (YYYYMMDD) NRD NAME DIVISION NRS NAME STATION ID NRS FAX #. RECRUITER NAME RECRUITER SSN PAYGRADE RATE LPO / WITNESS RECRUITER PHONE. STREET ADDRESS CITY STATE ZIP. NRS ADDRESS. APPLICANT INFORMATION. LAST NAME FIRST NAME MIDDLE NAME SUFFIX MALE FEMALE MARITAL STATUS DEPENDENTS. SOCIAL SECURITY NUMBER BIRTHDAY (YYYYMMDD) PARENTAL CONSENT? YES NO. PLACE OF BIRTH CITIZENSHIP NON CITIZEN. CITY STATE COUNTY COUNTRY US AT BIRTH NATIVE BORN BORN ABROAD NATURALIZED IMMIGRANT COUNTRY. UNITED STATES. VALID DRIVER'S LICENSE SELECTIVE SERVICE # RELIGION ALIEN REGISTRATION #. YES | NO STATE NUMBER EXPIRATION. ETHNIC CATEGORY. CURRENT ADDRESS HISPANIC OR LATINO. STREET ADDRESS CITY COUNTY STATE COUNTRY ZIP NOT HISPANIC OR LATINO. UNITED STATES RACIAL CATEGORY. HOME OF RECORD ADDRESS (IF SAME AS CURRENT PLACE "SAME AS BLOCK 3" IN STREET BLOCK) AMERICAN INDIAN/ALASKAN.

2 STREET ADDRESS CITY COUNTY STATE COUNTRY ZIP ASIAN. SAME AS BLOCK 3 BLACK OR AFRICAN AMERICAN. HT WT MX WT PARENTAL CONSENT (CHECK AS NEEDED / YES FOR PARENTAL CONSENT NEEDS TO BE SELECTED ABOVE) NATIVE HAWAIIAN / PACIFIC ISLANDER. MOTHER FATHER WHITE. GUARDIAN 1 GUARDIAN 2. PROCESSING INFORMATION DOCUMENT VERIFICATION. ACTIVE RESERVE DNR / DNV ED CODE AFQT EST NAME AGE. D N R BIRTH CERTIFICATE BIRTH CERTIFICATE. PROCESSING DATE TIME OF ARRIVAL LODGING NEEDED? OTHER OTHER. SPECIFY: SPECIFY: NIGHT TEST HS PULL REQUIRED CITIZENSHIP SOCIAL SECURITY NUMBER. SAME DAY PROCESSING NAVET BIRTH CERTIFICATE SSN CARD. PHYSICAL ONLY OSVET OTHER OTHER. ASVAB INFORMATION SPECIFY: SPECIFY: NEVER TESTED PREVIOUS VERSION ASVAB REQUIRED? USE STUDENT SCORES? EDUCATION OTHER DOCUMENTS USED: YES NO YES NO HS DIPLOMA. HAVE TESTED PREVIOUS DATES OTHER. TYPE RETEST SPECIFY: REQUEST STUDENT SCORES DATE TESTED INITIAL 1ST NAME DIFFERENT? NAME ON SSN CARD. SPECIAL 2ND YES NO.

3 KEEP AFQT SCORES LOCATION TESTED CONFIRMATION IMMEDIATE NAME ON BIRTH CERTIFICATE. RESET RETEST 6 MONTH. FOREIGN LANGUAGE MEPS MEDICAL EXAM REQUIRED? PREFERRED NAME. YES NO YES NO. LANGUAGE 1 LANGUAGE 2 TYPE OF MEDICAL EXAM BIRTH CERT ISSUED BY HS DIPLOMA OR OTHER EDUCATION. NONE FULL CONSULT DOCUMENT ISSUED BY. (1ST) 2 DIGIT CODE (2ND) 2 DIGIT CODE INSPECT RE-EXAM OTHER BIRTH VER DOCUMENT. SPECIAL OTHER. LANGUAGE CODES BEGIN ON PAGE 82 OF COLLEGE. WAIVER INFORMATION. VOLUME III OF THE CRUITMAN. YES TRANSCRIPTS. NONE CIVIL DRUG DEPENDENCY NO DIPLOMA. ISSUED BY. OTHER EXPLAIN. WAIVER LEVEL ONLY SELECT YES FOR COLLEGE IF YOU HAVE DIPLOMA. NAVCRUITDIST COMNAVCRUITCOM OR TRANSCRIPTS ON HAND!! DD-93 & OTHER DOCUMENT INFORMATION. BIRTH MOTHER (LAST, FIRST MI) FULL ADDRESS (STREET, CITY, STATE, ZIP) PHONE NUMBER RELATIONSHIP %. MOTHER. BIRTH FATHER (LAST, FIRST MI) FULL ADDRESS (STREET, CITY, STATE, ZIP) PHONE NUMBER RELATIONSHIP %. FATHER.

4 SPOUSE / GUARDIAN 1 (LAST, FIRST MI) FULL ADDRESS (STREET, CITY, STATE, ZIP) PHONE NUMBER RELATIONSHIP %. OTHER / GUARDIAN 2 (LAST, FIRST MI) FULL ADDRESS (STREET, CITY, STATE, ZIP) PHONE NUMBER RELATIONSHIP %. DD-93 GRATUITY / PAY / ALLOWANCES / PADD. MOTHER FATHER SPOUSE / GUARDIAN 1 OTHER / GUARDIAN 2. DEATH GRATUTITY DEATH GRATUTITY DEATH GRATUTITY DEATH GRATUTITY PRINT 680/2807. UNPAID PAY/ALLOWANCES UNPAID PAY/ALLOWANCES UNPAID PAY/ALLOWANCES UNPAID PAY/ALLOWANCES. PADD PADD PADD PADD. DD-93 CHILDREN PRINT 680/2807 WITH PC. NAME (Last, First MI) RELATIONSHIP BIRTHDAY ADDRESS. PRINT BASIC KIT TATTOO DOCS. WILLGRAD EDVER. 1966 / EDVER / OTHER INFORMATION PRINT DEPENDENCY WAIVER. SCHOOLS GRADUATE? FROM TO NAME OF SCHOOL LOCATION YES NO. PRINT CIVIL WAIVER. PRINT DRUG/ALCOHOL WAIVER. HIGH SCHOOL NAME HIGH SCHOOL ADDRESS PHONE NUMBER COUNTRY (IF FOREIGN). <------ EDVER INFORMATION. PROCESSING DATA WORKSHEET. SSN: -- DEP DER. NAME: , MALE FEMALE.

5 RACE: CAUCASIAN BLACK HISPANIC ASIAN PACIFIC ISLANDER. ED LVL LODGING: YES NO AFQT: PROCESSING DATE: TIME OF ARRIVAL: STATION ID: RECRUITER: ASVAB INFORMATION: INITIAL RETEST CONFIRMATION. MEDICAL: FULL EXAM INSPECT CONSULT. WAIVER REQUIRED NONE CIVIL DRUG DEPENDENCY OTHER _____. WAIVER LEVEL: N/A NAVCRUITDIST COMNAVCRUITCOM. OTHER INFORMATION: NIGHT TEST SAME DAY PROCESSING PHYSICAL ONLY. NAVET OSVET HS PULL REQUIRED. REMARKS: GO TO FIRST PAGE. Applicant's Name , SSN -- Age AFQT Recruiter's SSN -- NRS Station ID Education Date to Process Circle, (X) or Indicate (N/A) as appropriate NOTE: More than one entry per item may apply DD form 1966 Waiver Type of Waiver Waiver Authority Waiver Conducted Date: Required Page 1 Page 2 Page 3 Page 4 Page 5 Civil NRD. Yes Waiver Documentation: Yes Other Forms and WCS MEPS Drug CNRA. Documents Required No No PGM CNRC. NASIS SF-86 Printed /Sign Copy N/A. Other BUMED. DD form 2807-2 DD form 369's (PRC's) Sent To Date Out Date In (All 6 Pages).

6 MEPCOM 680-3A-E. Name Verification Age Verification Citizenship Verification Education Other Documents WCS MEPS. Verification NAVCRUIT form 1133/97 Classifier Input Parent/Applicant Declaration of Desertion References NAVCRUIT form 1130/120. USN Aberrant Behavior Screening High School / College Transcripts OPNAV 5350/1 Drug and Alcohol Abuse Statement of Understanding Handwritten Statements #. Marriage Certificate Divorce/Seperation Decree DD form 368. DD form 214. (Write In). DD- 93, FRATERNIZATION PAGE. Financial Statement SIGN and Date entries below as appropriate Recruiter Enlistment - Reenlistment Checkoff Sheet WCS** Dep In Processor** EPDS Review/Date**. Classifier** Dep In MLPO** Quality Control Residual OMB No. 0704-0173. FOR USE OF THIS form , REQUEST FOR EXAMINATION. SEE USMEPCOM REG 680-3 OMB approval expires FOR OFFICIAL USE ONLY THE INFORMATION PROVIDED CONSTITUTES AN OFFICIAL STATEMENT. Sep 30, 2017. The public reporting burden for this collection of information is estimated to average 22 minutes per response, including the time for reviewing instructions , searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

7 Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to Headquarters, Military Entrance PROCESSING Command, Operations Directorate, 2834 Green Bay Road, North Chicago, IL 60064-3094. Read Privacy Act Statement on back before completing form . A. SERVICE PROCESSING FOR B. PRIOR SERVICE C. SELECTIVE SERVICE CLASSIFICATION D. SELECTIVE SERVICE REGISTRATION NUMBER. Yes No NAVY D N R NUMBER OF DAYS 0 N/A. 1. SOCIAL SECURITY NUMBER 2. NAME (Last, First, Middle Name (and Maiden, if any), Jr., Sr., etc.). - - , 3. CURRENT ADDRESS 4. HOME OF RECORD ADDRESS. (Street, City, County, State, Country, ZIP Code) (Street, City, County, State, Country, ZIP Code). SAME AS BLOCK 3. , , , , UNITED STATES, 5. CITIZENSHIP (X one) 6. SEX (X one) ETHNIC CATEGORY (X one). a. AT BIRTH ( If this box is marked, also X (1) or (2)) a. MALE b. FEMALE (1) HISPANIC OR LATINO (2) NOT HISPANIC OR LATINO.

8 (1) NATIVE BORN (2) BORN ABROAD OF PARENT(S) 8. MARITAL STATUS RACIAL CATEGORY (X all that apply). (Specify). b. NATURALIZED c. NON-CITIZEN NATIONAL (1) AMERICAN INDIAN/ALASKA NATIVE (2) ASIAN. d. IMMIGRANT ALIEN (Specify) (3) BLACK OR AFRICAN AMERICAN. 9. NUMBER OF. e. NON-IMMIGRANT FOREIGN NATIONAL (Specify) DEPENDENTS (4) NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER. f. ALIEN REGISTRATION NUMBER (As applicable) (5) WHITE. 10. DATE OF BIRTH (YYYYMMDD) 11. RELIGIOUS PREFERENCE (Optional) 12. EDUCATION (Yrs/Highest Ed Gr completed) 13. PROFICIENT IN FOREIGN LANGUAGE (X one) 1st 2nd Yes No NONE (If Yes, specify). 14. VALID DRIVER'S LICENSE (X one) (If Yes, list State, number, and expiration date) 15. PLACE OF BIRTH (City, State, and Country). Yes No ,, , , UNITED STATES. 16. APTITUDE: a. ASVAB REQUIRED TO ENLIST? c. TEST TYPE d. RETEST TYPE e. PREVIOUS TEST VERSIONS. (X one) Yes No INITIAL 1ST RETEST 2ND RETEST 1. 2. b. ENLIST UNDER STUDENT TEST SPECIAL 6 MONTH RETEST f.

9 PREVIOUS TEST DATES (YYYYMMDD). (X one) Yes No CONFIRMATION IMMED RETEST AUTHORIZED 1. 2. RECRUITER ID/SSN b. STATION ID 18. TEST ADMINISTRATOR SSN/ID 19. TEST ADMINISTRATOR SIGNATURE. -- 20. MEDICAL: a. MEPS MEDICAL EXAM REQUIRED TO ENLIST? b. EXAM TYPE FULL SPECIAL RE-EXAM c. DATE LAST FULL MEDICAL. (X one) Yes No INSPECT CONSULT OTHER EXAM (YYYYMMDD). 21. APPLICANT'S SIGNATURE 22. MIRS CODING. WKID ST DATE INT DATE INT. 23. APPLICANT CERTIFICATION IN PRESENCE OF TEST ADMINISTRATOR 24. RIGHT THUMBPRINT. I certify that I am the person identified on this form : Photo ID? (X one) Yes No RIGHT THUMBPRINT, FIRST ATTEMPT. If Yes, type/organization: (Affix thumbprint with thumbnail pointed to the left.). ID Number: (Signature of Applicant). 25. APPLICANT CERTIFICATION IN PRESENCE OF RECRUITING PERSONNEL. I certify that I am the person identified on this form and the information about me shown there, including my Social Security Number is all true and correct to the best of my knowledge.

10 I also certify that: a. I have never been tested ANYTIME or ANYWHERE with the ASVAB either for enlistment purposes or as a student under the ASVAB testing program. b. I was tested with the ASVAB on or about at (Most Recent Date Tested) (School, City, and State). c. Request for student test scores (high school look-up) at (Most Recent Date Tested) (School, City, and State). d. Yes, I want to keep my AFQT scores from the student test listed in "c" above. e. Current or last high school attended /. (High School) OR (13 Digit Code) IF SECOND ATTEMPT IS REQUIRED: f. / / Turn form over (Top of form on the bottom). -- Affix right thumbprint on upper right corner, (Signature of Applicant) (Social Security Number) (Date) thumbnail pointed to the left. MEDICAL RECORDS RELEASE AUTHORITY: I request and authorize individuals, businesses or organizations to release to Representatives of USMEPCOM my complete medical records. This release of medical information is for the sole purpose of further evaluation of my medical acceptability into the Armed Services.