PRSG enlisted-candidate-application-form

1. PUERTO RICO NATIONAL GUARD
STATE COMMAND
REQUISITOS DE INGRESO EN LA GUARDIA ESTATAL DE PUERTO RICO
- ENLISTADO-
1. SOLICITUD DE INGRESO FORMA 104 O 102
2. FORMA 104-A (ENLISTED ONLY)
3. RESUME PERSONAL
4. DATA PERSONAL PARA EMERGENCIA FORMA 107
5. CERTIFICADO DE BUENA CONDUCTA
6. CERTIFICADO DE NACIMIENTO
7. CERTIFICADO DE LICENCIA, (COPIA) ENFERMEROS, DOCTORES, INGENIEROS, ETC.
8. SERVICIO PREVIO – SOMETA FORMA DD-214, NGB 22 Ó EQUIVALENTE.
9. EXAMEN MÉDICO – POR UN MÉDICO DE VETERANOS, GUARDIA NACIONAL O GUARDIA ESTATAL.
10. ANÁLISIS DE SANGRE, ORINA, ETC.
11.TIPO DE SANGRE
12. FORMA 2006
13.(1) FOTOGRAFÍA
14. ENTREVISTA POR EL COMANDANTE DE LA UNIDAD A INGRESAR Y TRAER PÁRRAFO Y LÍNEA
DE LA POSICIÓN DISPONIBLE PARA INGRESO.
15. CERTIFICACIÓN DE ASUME
16. PRUEBA DE DOPAJE
17. CERTIFICADO DE MATRIMONIO
18.2 FOTOS 2X2 DE LA ESPOSA O ESPOSO
19.CERTIFICADO DE NACIMIENTO Y 2 FOTOS 2X2 PARA HIJOS DE 10 A 21 AÑOS DE EDAD/
20. ID CARD SE SEPARAN DE MARTES A JUEVES DE 10:00 AM – 11:30 AM Y DE 1:00 PM – 3 :00 PM

2. ENLISTMENT RECORD
SECTION I - APPLICATION FOR ENLISTMENT
2. SERVICE NUMBER (Social Security)
1. NAME OF APPLICANT (Last name, first name middle name)
5. P. R. STATE GUARD UNIT (Company and Battalion)
8. CITIZENSHIP 9. DATE OF BIRTH
6. INITIAL ASSIGNMENT 7. GRADE
3. CURENT MAIL ADDRESS (Include zip code) 4. FORMER MILITARYSERVICE NUMBER (S)
11. HEIGHT
17. CONDITION OF HEALTH
20. NAME AND ADDRESS OF PRESENT EMPLOYER OR FIRM
23. HEVE YOU EVER BEEN CONVICTED OF A FELONY? (Submit report of Good Conduct with Application)
24. CIVILIAN EDUCATION (List high schools, trade schools, colleges, and universities attended)
25. PRIOR MILITARY SERVICE (List each tour of duty, promotion, transfer, duty assignment and unit)
26. SERVICE MEDALS, COMMENDATIONS, CITATIONS AND DECORATIONS AWARDED
27. MILITARY SCHOOLS COMPLETED
I certify that the above is a true and correct statement of my personal history, educational background and military experience. I hereby voluntarily
enlist for an indefinite period as an enlisted in the Puerto Rico State Guard, under the conditions prescribed
by law, until discharged by proper authority.
Name of Course
Name of School Location (City & State) Graduated?
Date From Date To Grade Armed Force Branch Duty Assignment Unit and Station (Location)
Year Degree or Rating Awarded
22. HOW LONG IN PRESENT JOB
21. YOUR JOB TITLE
18. MARITAL STATUS 19. NAME OF SPOUSE (Include first name and maiden name)
12. WEIGHT 13. COLOR OF EYES
Name of Service School and Location Year Completed Qualification Awarded
10. PLACE OF BIRTH
14. COLOR OF HAIR 16. IDENTIFYING MARK/SCARS
15. COMPLEXION
_____________________________
DATE OF ENLISTMENT
_______________________________________________________
SIGNATURE OF VOLUNTEER
Page-1
- PRSG - FORM 104 - FOR COL APPROVAL - 08/2008

3. SECTION II - CERTIFICATION BY UNIT COMMANDER
SECTION III - OATH OF ENLISTMENT
SECTION IV - IDENTIFICATION CARD REGISTER
SECTION V - RECORD OF AWARDS AND DECORATIONS NOT PREVIOUSLY RECORDED
33.
34.
SECTION VI - SERVICE RECORD SUBSEQUENT TO ENLISTMENT
SECTION VII - FINAL ENDORSEMENT FOR DISCHARGE
I certify that I have conducted an interview with the applicant. A review of his/her Certificate of Good Conduct indicates the applicant for enlistment has the
following police record (other than minor traffic violations)
Initial issue of Puerto Rico State Guard Identification Card # _________________________ on _________________________ .
Above numbered Identification Card was reissued on the following dates:
______________ ______________ ______________ ______________ ______________ ______________
To: HEADQUARTERS, PUERTO RICO STATE GUARD, This enlisted man was discharged from the Puerto Rico State Guard effective _______________ 20___, in
the grade of ___________, by Order Number_______, dated __________________20___, reason of _____________________________________________.
I, _________________________________________________ , do solemnly swear that I will bear true faith and allegiance to the state of Puerto Rico
and to the United States of America; that I will serve them honestly and faithfully against all their enemies whomsoever, and that I will obey the orders
of the Governor of Puerto Rico, and the orders of the officers appointed over me, according to the laws, rules and articles for the government of the
Military Forces of the Commonwealth of Puerto Rico.
Through the interview and examination of educational and military records, I verify the valid of the statements made in the application for enlistment, and enlistment
in the grade of:
______________________________________
(SIGNATURE OF COMMANDER)
______________________________________
SIGNATURE
______________________________________________
(SIGNATURE OF OFFICER ADMINISTERING OATH)
______________________________________________
SIGNATURE OF COMMANDING OFFICER
_______________________________________
(PRINTED NAME AND GRADE)
32.
31.
30.
29.
Subscribed and sworn before me at ______________________ , Puerto Rico, on this ________ day of ____________ 20____.
Page-2
PERMANENT ORDERS NUMBER & DATE
EFFECTIVE DATE GRADE DUTY ASSIGNMENT P. R. STATE GUARD UNIT ORDERS NUMBER & DATE
EFFECTIVE DATE
AWARD

4. LAST NAME
DATE OF INTERVIEW GRADE, NAME, ORG & TITLE OF COMMANDER SIGNATURE OF COMMANDER
APPLICANT HAS BEEN INTERVIEWED AND IS
OTHER BACKGROUND DATA
MEMBERSHIP IN YOUTH PROGRAMS
2.
UDERSTANDINGS
4. CARACTER AND SOCIAL ADJUSTMENT
3.
DECLARATIONS
Have you ever been enrolled in an ROTC, Junior ROTC or Sea Cadet Program, or have been a member of the Civil Air Patrol? Optional entry
you may be entitled to a higher enlistment grade based on such membership and participation. If yes, enter organization and its address. On Back
a. Have you ever been rejected for enlistment, reenlistment or induction by any branch of the Armed Forces of the United States?
b. Are you now, or have ever been, a deserter from any branch of the Armed Forces of the United States?
c. Are you now drawing, or have any application pending, or approval for: Retired pay, disability allowance, severance pay, or a pension from the
Government of the United States?
d. Are you a conscientious objector? That is, do you have, or have you ever had, a firm fixed, and sincere objection to participation in war in any
form or to the bearing of arms because of religious training or belief?
e. Are you the only living child of your parents?
f. Have you ever been a draft evader or participate in an amnesty program?
g. Do you now have, or have you had within the past ten years, knowing membership with the specific intent of furthering the aims of, or adherence
to, and active participation in any foreign or domestic organization or association or movement or group or combination of persons which
unlawfully advocates or practices the commission os acts of force or violence to prevent others from exercising their rights under the
Constitution of the United States or subdivision thereof by unlawful means? (If yes, give the name (s) of the organization (s) and inclusive dates
of your membership) on back of form.
h. Have you ever visited a foreign country except as a member of the United States Armed Forces performing official duties? (If yes, give year and
month, countries visited, and purpose of travel on back of form).
I UNDERSTAND THAT IF I AM REJECTED FOR ENLISTMENT BECAUSE OF A DESQUALIFICATION THAH I HAVE CONCEALED, I MAY NOT BE
PROVIDED RETURN TRANSPORTATION FROM THE PLACE OF EXAMINATION TO MY HOME.
i. Have you ever worked for a foreign government? (If yes, give dates of employment, name of the government you worked for, and description and
location of your duties, on back of form).
1. If you answer to every question is truthfully "NO", initial in the appropriate space.
2. You are not required to answer or explain your responses to these questions in writing if your answer is "YES" or you have reservations about
answering questions of this nature. Instead, you may request a personal interview in which you may provide the required information for each
question orally.
a. If you choose the personal interview, the the information you give may be investigated; however any written record of the interview
itself will not be retained more than six months after your entry on active duty and will not become a part of your permanent military
personnel service record.
b. This information may be requested from you again at some future date if you enlist and may become a part of your security investigative
file at that time. This could occur as a result of your being considered for duties involving access to classified information or other types
of duties requiring a personnel security investigation.
3. A "YES" answer will not necessarily disqualify you for enlistment; it will depend on the circumstances surrounding the situation involved.
INITIAL HERE IF YOU PREFER A PERSONAL INTERVIEW: ________________
DO NOT WRITE IN THIS BLOCK - TO BE COMPLETED BY: UNIT COMMANDER
1. NO
INITIALS
YES
SSAN
Page-3
ELEGIBLE FOR ENLISTMENT INELEGIBLE FOR ENLISTMENT

5. MILITARY
FORCES
OF
PUERTO
RICO
PUERTO
RICO
STATE
GUARD
HEADQUARTERS
San
Juan,
Puerto
Rico
00902-3786
EMERGENCY
DATA
CARD
1.
______________________________,
_________________________,
__________________
(SPOUSE
NAME)
(LAST
NAME)
(FIRST)
(MI)
(SSN)
6.
______________________________,
_________________________,
__________________
4.
_______________________________________________________________________,
____________________________,
_____________________,
__________,
_______________
5.
_______________________________________________________________________,
____________________________,
_____________________,
__________,
_______________
(NAME)
(HOME
ADDRESS)
(POSTAL
ADDRESS)
(TOWN)
(TOWN)
(CITY)
(STATE)
(ZIP
CODE)
8.
_______________________________________________________________________,
____________________________,
_____________________,
__________,
_______________
______________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________
9.
PERSON
TO
NOTIFY
IN
CASE
OF
EMERGANCY
(PLEASE
CLEARLY
PRINT
ADDRESS
AND
TELEPHONES
IN
SPACE
BELOW)
____________________________________________________________
SERVICE
MEMBER
SIGNATURE
____________________________________________________________
PRSG
FORM
107
(Revised
16
May
2005)
(ADITIONAL
INFORMATION
USE
BACK
OF
FORM)
____________________________________________________________
DATE
SIGNED
(CITY)
(HOME
ADDRESS)
(STATE)
(ZIP
CODE)
(TOWN)
(CITY)
(STATE)
(ZIP
CODE)
(LAST
NAME)
(FIRST)
(MI)
(SSN)
(GROUP)
(BN)
(COMPANY)
2.
________-______-________
3.
_______________,
___________,
__________________
________-______-________
(HOME
PHONE
NO.)
(CELL
PHONE
NO.)
7.
______________________________,
_________________________,
__________________
(CLOSEST
NEX
OF
KIN
NAME)
(LAST
NAME)
(FIRST)
(MI)
(SSN)
________-______-________
(
)
-
-
(HOME
PHONE
NO.)
(
)
-
-
(CELL
PHONE
NO.)
(
)
-
-
(
)
-
-
Page-4

6. CERTIFICATION OF ELIGIBILITY TO RECEIVE WEAPON AND AMMUNITION
PURSUANT TO 18 U. S. C. 922
I. It is against the law for any soldier or civilian who has been convicted of a misdemeanor
crime of domestic violence to posses a weapon or ammunition. The maximum penalty
for violating this law is a fine up to $250,000.00 and imprisonment of to ten years. A
misdemeanor which involves physical force or threatened use of a weapon by one
family member against another. If you have any questions concerning the definition of a
“misdemeanor crime of domestic violence” consult the commander prior to signing this
form. ________________ (initials).
II. By signing this form, I certify that I have never been convicted of a misdemeanor crime
of domestic violence to that person. ________________ (initials).
III. I am not currently under a court order to refrain from contact with any person based
upon a previous act or threat of violence to that person. ________________ (initials).
IV. I will notify my commander if I am convicted of a misdemeanor crime of domestic
violence in any court after signing this form. ________________ (initials).
I certify that each of the statements in paragraphs II-IV, above is true and correct. I have been
advised that making a false statement is a crime under 18 U. S. C. 1001, which is punishable by
a fine of not more that $10,000.00 or imprisonment for not more than 5 years or both. In
addition, military personnel may be punished under the Uniform Code of Military Justice
(UCMJ).
____________________
UNIT
________________________________
Signature
________________________________
SSN

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11. MEDICAL RECORD REPORT OF MEDICAL EXAMINATION
DATE OF EXAM
1. LAST NAME - FIRST NAME - MIDDLE NAME 2. IDENTIFICATION NUMBER 3. GRADE AND COMPONENT OR POSITION
4. HOME ADDRESS (Number, street or RFD, city or town, state and ZIP Code) 5. EMERGENCY CONTACT (Name and address of contact)
6. DATE OF BIRTH 7. AGE 8. SEX
FEMALE MALE
9. RELATIONSHIP OF CONTACT
10. PLACE OF BIRTH 11. RACE
WHITE BLACK
AMERICAN INDIAN/
ALASKA NATIVE
HISPANIC
WHITE
HISPANIC
BLACK
ASIAN/PACIFIC
ISLANDER
12a. AGENCY 12b. ORGANIZATION UNIT 13. TOTAL YEARS GOVERNMENT SERVICE
a. MILITARY b. CIVILIAN
14. NAME OF EXAMINING FACILITY OR EXAMINER, AND ADDRESS 15. RATING OR SPECIALTY OF EXAMINER
16. PURPOSE OF EXAMINATION
17. CLINICAL EVALUATION
NOR-
MAL
ABNOR-
MAL
(Check each item in appropriate column, enter NE if not evaluated.)
A. HEAD, FACE, NECK AND SCALP
B. EARS - GENERAL (INTERNAL CANALS)
(Auditory acuity under items 39 and 40)
C. DRUMS (Perforation)
D. NOSE
E. SINUSES
F. MOUTH AND THROAT
G. EYES - GENERAL (Visual acuity and refraction under items 28, 29, and 36)
H. OPTHALMOSCOPIC
I. PUPILS (Equality and reaction)
J. OCULAR MOTILITY (Associated parallel movements nystagmus)
K. LUNGS AND CHEST
L. HEART (Thrust, size, rhythm, sounds)
M. VASCULAR SYSTEM (Varicosities, etc.)
N. ABDOMEN AND VISCERA (Include hernia)
O. PROSTATE (Over 40 or clinically indicated)
P. TESTICULAR
Q. ANUS AND RECTUM (Hemorrhoids, Fistulae) (Hemocult Results)
R. ENDOCRINE SYSTEM
S. G-U SYSTEM
T. UPPER EXTREMITIES (Strength, range of motion)
U. FEET
V. LOWER EXTREMITIES (Except feet) (Strength, range of motion)
W. SPINE, OTHER MUSCULOSKELETAL
X. IDENTIFYING BODY MARKS, SCARS, TATTOOS
Y. SKIN, LYMPHATICS
Z. NEUROLOGIC (Equilibrium tests under item 41)
AA. PSYCHIATRIC (Specify any personality deviation)
BB. BREASTS
CC. PELVIC (Females only)
NOR-
MAL
ABNOR-
MAL
(Check each item in appropriate column, enter NE if not evaluated.)
NOTES: (Describe every abnormality in detail. Enter pertinent item number before each comment. Continue in item 42 and use additional sheets if necessary.)
18. DENTAL (Place appropriate symbols, shown in examples, above or below number of upper and lower teeth.) REMARKS AND ADDITIONAL DENTAL
DEFECTS AND DISEASES
R
I
G
H
T
L
E
F
T
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17
1
32
0
2
31
0
3
30
Restorable
Teeth
1
32
/
2
31
/
3
30
Missing
Teeth
1
32
X
2
31
X
3
30
Non-
restorable
Teeth
X
1
32
X
X
2
31
X
X
3
30
X
Replaced
by
Dentures
(
1
32
(
X
2
31
X
)
3
30
)
Fixed
Partial
Dentures
19. TEST RESULTS (Copies of results are preferred as attachments)
A. URINALYSIS: (1) SPECIFIC GRAVITY
(2) URINE ALBUMIN
(3) URINE SUGAR
(4) MICROSCOPIC
B. CHEST X-RAY OR PPD (Place, date, film number and result)
C. SYPHILIS SEROLOGY (Specify test used
and results)
D. EKG E. BLOOD TYPE AND RH
FACTOR
F. OTHER TESTS
NSN 7540-00-634-4038
88-126
Designed using Perform Pro, WHS/DIOR, Jan 97
STANDARD FORM 88 (Rev. 10-94) (EG)
Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1

12. NO. OF SHEETS ATTACHED
NAME IDENTIFICATION NUMBER
MEASUREMENTS AND OTHER FINDINGS
20. HEIGHT 21. WEIGHT 22. COLOR HAIR 23. COLOR EYES 24. BUILD
SLENDER MEDIUM HEAVY OBESE
25. TEMPERATURE
26. BLOOD PRESSURE (Arm at heart level) 27. PULSE (Arm at heart level)
A.
SITTING
SYS.
DIAS.
B.
RECUM-
BENT
SYS.
DIAS.
C.
STANDING
(5 mins.)
SYS.
DIAS.
A. SITTING B. RECUMBENT C. STANDING
(3 mins)
D. AFTER EXERCISE E. 2 MINS. AFTER
28. DISTANT VISION
RIGNT 20/
LEFT 20/
CORR. TO 20/
CORR. TO 20/
29. REFRACTION
BY
BY
S.
S.
CX
CX
30. NEAR VISION
CORR. TO
CORR. TO
BY
BY
31. HETEROPHORIA (Specify distance)
ESO EXO R.H. L.H. PRISM DIV. PRISM CONV.
CT
PC PD
32. ACCOMMODATION
RIGHT LEFT
33. COLOR VISION (Test used and result) 34. DEPTH PERCEPTION
(Test used and score)
UNCORRECTED
CORRECTED
35. FIELD OF VISION
RIGHT LEFT
36. NIGHT VISION (Test used and score) 37. RED LENS TEST 38. INTRAOCULAR TENSION
RIGHT LEFT
39. HEARING
RIGHT W/V /15SV /15
LEFT W/V /15SV /15
40. AUDIOMETER
RIGHT
LEFT
250
256
500
512
1000
1024
2000
2048
3000
2896
4000
4096
6000
6144
8000
8192
41. PSYCHOLOGICAL AND PSYCHOMOTOR (Tests used and score)
42. NOTES (Continued) AND SIGNIFICANT OR INTERVAL HISTORY
(Use additional sheets if necessary)
43. SUMMARY OF DEFECTS AND DIAGNOSES (List diagnoses with item numbers)
44. RECOMMENDATIONS - FURTHER SPECIALIST EXAMINATIONS INDICATED (Specify) 45A. PHYSICAL PROFILE
P U L H E S
45B. PHYSICAL CATEGORY
A B C
46. EXAMINEE (Check)
A. IS QUALIFIED FOR
B. IS NOT QUALIFIED FOR
47. IF NOT QUALIFIED, LIST DISQUALIFYING DEFECTS BY ITEM NUMBER
48. TYPED OR PRINTED NAME OF PHYSICIAN SIGNATURE
49. TYPED OR PRINTED NAME OF PHYSICIAN SIGNATURE
50. TYPED OR PRINTED NAME OF DENTIST OR PHYSICIAN (Indicate which) SIGNATURE
51. TYPED OR PRINTED NAME OF REVIEWING OFFICER OR APPROVING AUTHORITY SIGNATURE
STANDARD FORM 88 (Rev. 10-94) BACK
E

13. MEDICAL RECORD REPORT OF MEDICAL HISTORY
DATE OF EXAM
NOTE: This information is for official and medically-confidential use only and will not be released to unauthorized persons
1. NAME OF PATIENT (Last, first, middle) 2. IDENTIFICATION NUMBER 3. GRADE
4a. HOME STREET ADDRESS (Street or RFD; City or Town; State; and ZIP Code) 5. EXAMINING FACILITY
6. PURPOSE OF EXAMINATION
NO. OF ATTACHED SHEETS:
STANDARD FORM 93 (REV. 6-96)
Prescribed by ICMR/GSA
FIRMR (41 CFR) 201-9.202-1
4b. CITY 4c. STATE 4d. ZIP CODE
d. HEIGHT e. WEIGHT
8. PATIENT'S OCCUPATION 9. ARE YOU (Check one)
RIGHT HANDED LEFT HANDED
10. PAST/CURRENT MEDICAL HISTORY
Arthritis, Rheumatism, or
Bursitis
Thyroid trouble or goiter
Eating disorder (anorexia bulimia,
etc.)
c. ALLERGIES (Include insect bites/stings and common foods)
YES NO
DON'T
KNOW
CHECK EACH ITEM
Scarlet fever
Rheumatic fever
Swollen or painful joints
Frequent or severe headaches
Dizziness or fainting spells
Eye trouble
Hearing loss
Suicide attempt or plans
Sleepwalking
Wear corrective lenses
Stutter or stammer
Wear a brace or back support
Lack vision in either eye
Wear a hearing aid
Eye surgery to correct vision
Household contact with anyone
with tuberculosis
Tuberculosis or positive TB test
Blood in sputum or when
coughing
Excessive bleeding after injury or
dental work
Recurrent ear infections
Chronic or frequent colds
Severe tooth or gum trouble
Sinusitis
Hay fever or allergic rhinitis
Head injury
YES NO
DON'T
KNOW
CHECK EACH ITEM
Kidney stone or blood in urine
Sugar or albumin in urine
Sexually transmitted diseases
Recent gain or loss of weight
Jaundice or hepatitis
Broken bones
Adverse reaction to medication
Tumor, growth, cyst, cancer
Hernia
Hemorrhoids or rectal disease
Frequent or painful urination
Bed wetting since age 12
Shortness of breath
Pain or pressure in chest
Chronic cough
Palpitation or pounding heart
Heart trouble
High or low blood pressure
Cramps in your legs
Frequent indigestion
Gall bladder trouble or
gallstones
Asthma
CHECK EACH ITEM
Asbestos or toxic chemical
exposure
Plate, pin or rod in any bone
Easy fatigability
Been told to cut down or
criticized for alcohol use
Used illegal substances
Used tobacco
Trick or locked knee
Loss of finger or toe
Painful or trick shoulder
or elbow
Recurrent back pain or any
back injury
Foot trouble
Nerve Injury
Paralysis (including infantile)
Epilepsy or seizure
Car, train, sea or air sickness
Frequent trouble sleeping
Depression or excessive worry
Loss of memory or amnesia
Nervous trouble of any sort
Periods of unconsciousness
Parent/sibling with diabetes,
cancer, stroke or heart disease
X-ray or other radiation therapy
Chemotherapy
YES NO
DON'T
KNOW
Stomach, liver or intestinal trouble
Skin diseases
Bone, joint or other deformity
NSN 7540-00-181-8368
Previous edition not usable
7. STATEMENT OF PATIENT'S PRESENT HEALTH AND MEDICATIONS CURRENTLY USED (Use additional pages if necessary)
a. PRESENT HEALTH b. CURRENT MEDICATION REGULAR OR INTERM.

14. 25. PHYSICIAN'S SUMMARY AND ELABORATION OF ALL PERTINENT DATA (Physician shall comment on all positive answers in Items 7 through 11. Physician may
develop by interview any additional medical history deemed important, and record any significiant findings here.)
26c. DATE
26a. TYPED OR PRINTED NAME OF PHYSICIAN OR EXAMINER 26b. SIGNATURE
STANDARD FORM 93 (REV. 6-96) BACK
12. Have you been refused employment or been unable to hold a job or
stay in school because of:
a.Sensitivity to chemicals, dust, sunlight, etc.
b.Inability to perform certain motions.
c.Inability to assume certain positions.
d.Other medical reasons (If yes, give reasons.)
13. Have you ever been treated for a mental condition? (If yes, specify
when, where, and give details.)
14. Have you ever been denied life insurance? (If yes, state reason and
give details.)
15. Have you had, or have you been advised to have, any operation.
(If yes, describe and give age at which occurred.)
16. Have you ever been a patient in any type of hospital? (If yes,
specify when, where, why, and name of doctor and complete address
of hospital.)
17. Have you consulted or been treated by clinics, physicians, healers,
or other practitioners within the past 5 years for other than minor
illnesses? (If yes, give complete address of doctor, hospital, clinic, and
details.)
18. Have you ever been rejected for military service because of
physical, mental, or other reasons? (If yes, give date and reason for
rejection.)
19. Have you ever been discharged from military service because of
physical, mental, or other reasons? (If yes, give date, reason, and
type of discharge; whether honorable, other than honorable, for
unfitness or unsuitability.)
20. Have you ever received, is there pending, or have you ever applied
for pension or compensation for existing disability? (If yes, specify
what kind, granted by whom, and what amount, when, why.)
21. Have you ever been arrested or convicted of a crime, other than
minor traffic violations. (If yes, provide details.)
22. Have you ever been diagnosed with a learning disability? (If yes,
give type, where, and how diagnosed.)
I certify that I have reviewed the foregoing information supplied by me and that it is true and complete to the best of my knowledge. I authorize any of the doctors, hospitals,
or clinics mentioned above to furnish the Government a complete transcript of my medical record for purposes of processing my application for this employment or service. I
understand that falsification of information on Government forms is punishable by fine and/or imprisonment.
24c. DATE
24a. TYPED OR PRINTED NAME OF EXAMINEE 24b. SIGNATURE
NOTE: HAND TO THE DOCTOR OR NURSE, OR IF MAILED MARK ENVELOPE TO BE OPENED BY MEDICAL OFFICER ONLY.
23. LIST ALL IMMUNIZATIONS RECEIVED
11. FEMALES ONLY
CHECK EACH ITEM
Treated for a female disorder
Change in menstrual pattern
DATE OF LAST MENSTRUAL
PERIOD
DATE OF LAST PAP SMEAR DATE OF LAST MAMMO-
GRAM
YES NO
DON'T
KNOW
CHECK EACH ITEM. IF YES EXPLAIN IN BLANK SPACE TO RIGHT. LIST EXPLANATION BY ITEM NUMBER.
YES NO
ITEM