RASP/Augmentee Pre-Screening Questionnaire

1 RASP/Augmentee Pre-Screening QuestionnaireAUTHORITY: 10 Section 3013, Secretary of the Army; AR 600-20, Army Command Policy PRINCIPAL PURPOSE: To assess the suitability of a Soldier for service in the 75th Ranger Regiment. ROUTINE USE: None. The "Blanket Routine Uses" set forth at the beginning of the Army's Compilation of Systems of Record Notices also applies to this system. MANDATORY OR VOLUNTARY: Voluntary. However, failure to provide all the requested information may lead to an application being JAN 2022; this supersedes all previous editions of this Questionnaire FULL NAME: _____RANK: _____ ATTENTION: The information gathered from the Questionnaire will be used by the 75th Ranger Regiment in itsAssessment and Selection Process. Before you answer any questions below, please understand that you have the right to refuse to answer any of the questions listed below. You must also be aware that any information provided may be used against you in a criminal trial if necessary.

2 You have the right to talk to a lawyer before or after you have completed your Questionnaire . As an acknowledgement that you understand your rights, please digitally sign this document in the space below: I understand my rights as stated above _____ DATE:_____ ---------------------------------------- ---------------------------------------- ---------------------------------------- ----- -------------------------------- you currently have a valid Security Clearance? No, do you have an Interim Clearance? No, please engage your Security Clearance Section / Office. You arecurrently ineligible to attend RASP 2 or serve as an you ever been considered for a security clearance and been denied? YES, please you ever suspended or expelled from any school or college? YES, please you ever fired from a job, or did you quit for fear of being dismissed? YES, please you ever been arrested, detained, or charged with a criminal offense, even if thecharges were dropped or been told no record would be made of the incident?

3 YES, please you ever been convicted by a military court or been the subject of a criminalinvestigation conducted by a military investigative agency?If YES, please explain. _____ RASP/Augmentee Pre-Screening QuestionnaireAUTHORITY: 10 Section 3013, Secretary of the Army; AR 600-20, Army Command Policy PRINCIPAL PURPOSE: To assess the suitability of a Soldier for service in the 75th Ranger Regiment. ROUTINE USE: None. The "Blanket Routine Uses" set forth at the beginning of the Army's Compilation of Systems of Record Notices also applies to this system. MANDATORY OR VOLUNTARY: Voluntary. However, failure to provide all the requested information may lead to an application being JAN 2022; this supersedes all previous editions of this Questionnaire you ever been punished under Article 15, UCMJ?If YES, please explain. _____ you ever received a letter of reprimand? If so, what rank was the signing authority andhow was the letter filed? YES, please you ever been flagged (DA Form 268)?

4 YES, please you ever been barred from re-enlistment? YES, please you ever had a restraining order or no contact order issued to you? YES, please you ever filed for bankruptcy under Chapter 7 or 11? If so, when was the bankruptcyfiled and what was the amount? YES, please you ever had an account placed for collection, or had a check cashing privilege(s)revoked? YES, please you have a history of excessive or habitual use of alcohol, or ever had any alcohol-related arrests, incidents, or treatment? YES, please you have a history of nervous disorders or other emotional and/or mental problems? YES, please Pre-Screening QuestionnaireAUTHORITY: 10 Section 3013, Secretary of the Army; AR 600-20, Army Command Policy PRINCIPAL PURPOSE: To assess the suitability of a Soldier for service in the 75th Ranger Regiment. ROUTINE USE: None. The "Blanket Routine Uses" set forth at the beginning of the Army's Compilation of Systems of Record Notices also applies to this system. MANDATORY OR VOLUNTARY: Voluntary.

5 However, failure to provide all the requested information may lead to an application being JAN 2022; this supersedes all previous editions of this Questionnaire you ever suffered from anxiety, depression, or stress for which you required treatmentfrom a psychologist or psychiatrist? YES, please you ever consulted or been treated by a psychologist or psychiatrist for any otheremotional or mental problem? If so, for what? YES, please you ever experimented with illegal drugs, including marijuana? YES, please you ever grown, sold, supplied, or transferred illegal drugs, including marijuana? YES, please you ever tested positive for illegal or banned substances during a unit urinalysisinspection? YES, please you ever participated in a substance abuse rehabilitation program? YES, please you ever been found guilty or punished of committing an Equal Opportunity (EO) orSexual Assault/Sexual Harassment (SHARP) violation? YES, please you ever knowingly or accidentally mishandled government classified material?

6 YES, please Pre-Screening QuestionnaireAUTHORITY: 10 Section 3013, Secretary of the Army; AR 600-20, Army Command Policy PRINCIPAL PURPOSE: To assess the suitability of a Soldier for service in the 75th Ranger Regiment. ROUTINE USE: None. The "Blanket Routine Uses" set forth at the beginning of the Army's Compilation of Systems of Record Notices also applies to this system. MANDATORY OR VOLUNTARY: Voluntary. However, failure to provide all the requested information may lead to an application being JAN 2022; this supersedes all previous editions of this Questionnaire you ever been involved as the subject in any security violation or incident? YES, please you married? you engaged to be married? you pending legal separation from your spouse? YES, are you currently involved in a relationship with another person? you are or have been married, have you ever had an extramarital affair? YES, please YES, were legal charges filed against you for infidelity? you ever had an inappropriate relationship or sexual relations with a person legallymarried to another party not yourself?

7 YES, please you have children? YES, how many children do you have? you have children with different partners? YES, list how many different children you have, broken down by each many children/partners are you legally obligated to support with monetarycontributions? How many are you currently supporting? you ever engaged in or been accused of child neglect or abuse? YES, please Pre-Screening QuestionnaireAUTHORITY: 10 Section 3013, Secretary of the Army; AR 600-20, Army Command Policy PRINCIPAL PURPOSE: To assess the suitability of a Soldier for service in the 75th Ranger Regiment. ROUTINE USE: None. The "Blanket Routine Uses" set forth at the beginning of the Army's Compilation of Systems of Record Notices also applies to this system. MANDATORY OR VOLUNTARY: Voluntary. However, failure to provide all the requested information may lead to an application being JAN 2022; this supersedes all previous editions of this Questionnaire there any pending medical conditions in your immediate family or dependents whichmay manifest themselves during the assessment and cause you to take emergency leave?

8 YES, please much current debt do you have? the type and monetary nature of your are the measures you have taken to manage and pay your debt? you have any legal actions pending against you in any state? YES, please you submitted an application packet or inquired about applying to any other SpecialOperations organization other than the 75th Ranger Regiment? YES, please you plan on applying to any other Military Organization or Special Duty assignment otherthan the 75th Ranger Regiment while your application is being processed? YES, please month and year will you complete your service obligation to the Unites States Army? year do you plan to leave/separate from the United States Army? Pleaseexplain you previously attended RIP/ROP or RASP I/II? YES, please you ever Released For Standards (RFS) from the 75th Ranger Regiment? YES, please Pre-Screening QuestionnaireAUTHORITY: 10 Section 3013, Secretary of the Army; AR 600-20, Army Command Policy PRINCIPAL PURPOSE: To assess the suitability of a Soldier for service in the 75th Ranger Regiment.

9 ROUTINE USE: None. The "Blanket Routine Uses" set forth at the beginning of the Army's Compilation of Systems of Record Notices also applies to this system. MANDATORY OR VOLUNTARY: Voluntary. However, failure to provide all the requested information may lead to an application being JAN 2022; this supersedes all previous editions of this Questionnaire is the highest level of education that you have achieved (GED, High School,Bachelors, Masters, etc.) was your final Grade Point Average (or equivalent grading metric) in theeducation programs you have attended; please list all to the best of you ever taken any standardized academic tests such as the SAT, ACT, GMAT, GRE, YES, what tests did you take, how many times did you take each and what wasyour best score in each? you ever taken any standardized military aptitude/intelligence tests such as theASVAB, DLAB/DLAT, YES, what tests did you take, how many times did you take each and what wasyour best score in each? the approximate dates, scores/time, and purpose/reason of the two most recentassessments you conducted in each of the following Physical Fitness Test: mile Mile Foot Water Survival the approximate date and purpose of the two most recent Multi Source Assessmentand Feedback 360(MSAF) assessments you have information have you not provided in the answers above that is relevant for the 75thRanger Regiment to be aware of prior to selecting you?

10 Pre-Screening QuestionnaireAUTHORITY: 10 Section 3013, Secretary of the Army; AR 600-20, Army Command Policy PRINCIPAL PURPOSE: To assess the suitability of a Soldier for service in the 75th Ranger Regiment. ROUTINE USE: None. The "Blanket Routine Uses" set forth at the beginning of the Army's Compilation of Systems of Record Notices also applies to this system. MANDATORY OR VOLUNTARY: Voluntary. However, failure to provide all the requested information may lead to an application being JAN 2022; this supersedes all previous editions of this Questionnaire 47. What has your career or branch manager at Human Resource Command (HRC) said aboutyour desire to augment or be assigned to the 75th Ranger Regiment? Do they support yourprojected timeline? I certify that the above statements are true and accurate to the best of my knowledge and to the extent that I am willing to answer the provided questions. Digital Signature:_____ FULL NAME: _____RANK: _____ all Social Media/Web Platforms you have an account for and the number of followers/subscribers for each.