VOLUNTARY ADOS Checklist Version 8 T32 ADOS CHECKLIST

1 VOLUNTARY ADOS CHECKLIST Version 8 APPLICANT SIGNATURE: _____ VOLUNTARY ADOS CHECKLIST Version 8 POC: JFHQ-G3 (717) 861-6846 T32 ADOS CHECKLISTNAME: DATE: UNIT: UNIT/ORGANIZATION WHERE ADOS WILL BE PERFORMED: ADOS DUTY POSITION: STATEMENT OF NEED: PAARNG Application for Active Duty Operational Support (ADOS) Form Block 22 Signed by Records Custodian Block 24 Signed by Applicant Block 33 Signed by Unit Commander and Records Custodian Current NGB Form 23A, within 30 days of application date Verification of security clearance memorandum from the State Security Manager, within 30 days of application dateDA Form 705 (Army Physical Fitness Test Scorecard) with Record-Go APFT score, within 60 days of application date.

2 DA 5500 or 5501 (Body Fat Content Worksheet), within 6 months of application start date Waiver (1095/17 Years/Sanctuary/Separation Pay) Pregnancy test results (Females Only), within 15 days of start date HIV test, within last 2 years of start dateDo you agree to voluntarily attend IDT and AT periods? Are you an Employee of the Commonwealth of Pennsylvania? Are you a Pennsylvania National Guard Technician? No Yes or No Yes or Yes or No Current Individual Medical Readiness (IMR) Record indicating Periodic Health Assessment (PHA), within one year of start date Soldier Record Brief (SRB) VOLUNTARY ADOS CHECKLIST Version 8 VOLUNTARY ADOS CHECKLIST Version 8 POC.

3 JFHQ-G3 (717) 861-6846 T10 ADOS CHECKLIST (for T10 tours, complete in addition to T32 ADOS CHECKLIST )DA Form 1506 (Statement of Service), covering all active service over the last four yearsDD Form 2648-1 (Pre-separation Counseling CHECKLIST )DD Form 2958 (Service Member Career Readiness Standards/Individual Transition Plan CHECKLIST )PAARNG ADOS Form1_____DATA REQUIRED BY THE PRIVACY ACT OF 1974 AUTHORITY: PRINCIPLE PURPOSE: 32 USC 502To determine eligibility and schedule individuals for active duty operational support (ADOS)ROUTINE USES: To identify the applicant as a Reserve Component member and to issue active duty operational support orders.

4 DISCLOSURE: Completing this form is mandatory for individuals applying for active duty operational support. If not completed, applicant will not be eligible for the requested tour. PART I - APPLICANT 1. TO2. NAME (Last, First, MI)3. SSN4a. PERMANENT HOME ADDRESS (Include ZIP code) 5a. ADDRESS FROM WHICH YOU WILL REPORT FOR DUTY (if different from permanent home address) (include ZIP code) 4b. HOME TELEPHONE NUMBER (Include area code) 5b. HOME TELEPHONE NUMBER (Include area code) 4c. BUSINESS TELEPHONE NUMBER (Include area code) 5c. BUSINESS TELEPHONE NUMBER (Include area code) 6. UNIT OF ASSIGNMENT OR ATTACHMENT7.

5 GRADE8. BRANCH/MOS9. SEX10. MARITAL STATUS12. NO. OF DEPENDANTSM F 13. PRIMARY SSI (AOC)/MOS14. DUTY SSI (AOC)/MOS 15. HEIGHT16. WEIGHT17. drawing a pension, disability 18. TOTAL AD PointsI am I am not compensation, or retired pay from the Government OF JFHQ HUMAN RESOURCE OFFICER VERIFYING ADMIN DATA IN BLOCK 1820. DATES OF ADOS REQUESTED:a. FIRST CHOICEb. SECOND CHOICENUMBER OF DAYS BEGINNING DATE/TIME NUMBER OF DAYS BEGINNING DATE/TIME LOCATION LOCATION DUTY/TRAINING AGENCY DUTY/TRAINING AGENCY 21. To the best of my knowledge and belief, I am physically qualified for active military service.

6 I was:a. LAST EXAMINED SIGNATURE OF COMPANY RECORDS CUSTODIAN23. DATEPAARNG ADOS Form224. REMARKS "I understand that, although at the completion of my tour, I may be within 2 years of qualifying for an active duty retirement under 10 USC 1293, 3911, or 3914, it is current Army policy that I will be released from ADOS at the completion of my tour unless I am offered a follow-on tour as approved by CNGB. I hereby waive sanctuary and consent to being ordered to ADOS for a period indicated on my order and consent to my release from ADOS at the completion of this tour." _____ (Signature of applicant) (THIS ACTION WILL NOT BE APPROVED WITHOUT THE SOLDIER S SIGNATURE IN THIS BLOCK) _____ ADDITIONAL REMARKS: Identify Break In Service.

7 (Used to compute / verify days elapsed since last active duty operational support tour (31-Day Break)) (a) Date of the last day on ADOS status:.. (b) Date new tour of duty to start: Number of Days (subtract b from a):PART II - RECORDS CUSTODIAN 25. PAY ENTRY BASIC DATE26. SECURITY CLEARANCE27. DATE OF RANK28. RYE DATE29. ETS (Enlisted)30. MANDATORY REMOVAL DATE (Officers)31. HIV TEST DATE32. PANOGRAPHIC DENTAL X-RAY ON FILE YES NO Duty: List all AD performed within the past 4 years. NGB FORM 23A must be attached IF number of points exceed 730 PERIOD OF PRECEDING DUTYb. TYPE OF ADc. LOCATIONd. DUTY(B1 or B4 on NGB 23B) INSTALLATION PERFORMED FROM TO NO.

8 AD PTSSIGNATURE OF COMPANY COMMANDER OR SIGNATURE AUTH DATEGRADETITLE SIGNATURE OF COMPANY RECORDS CUSTODIAN DATE GRADE TITLE NAME, SIGNATURE AND TELEPHONE NUMBER OF STATE ADOS APPROVING AUTHORITY (Approving official check appropriate box) THIS TOUR APPLICATION IS APPROVED THIS TOUR APPLICATION IS NOT DATE GRADE APPROVED NAME AND OFFICE OF POC COMMERCIAL AND DSN TELEPHONE PAARNG ADOS Form 3