Oregon Army National Guard

The below information/documentation is required to complete the application for entrance into the Oregon Army National Guard.

COPY OF BIRTH CERTIFICATE

COPY OF SOCIAL SECURITY CARD

COPY OF DRIVERS LICENSE OR STATE ID

COPY OF HIGH SCHOOL DIPLOMA OR GED

COPY OF MARRIAGE LICENSE

COPY OF CHILDREN’S BIRTH CERTIFICATE

COPY OF LEGAL DOCUMENTS (DIVORCE, CHILD CUSTODY, ETC)

COPY OF COLLEGE TRANSCRIPTS

COPY OF MEDICAL RECORDS

COPY OF NGB 22/ DD 214

BANK INFORMATION (SEE LAST PAGE OF APPLICATION)

Your Oregon Army National Guard Recruiter is:

OREGON ARMY NATIONAL GUARD ENLISTMENT DATASHEET

COMPLETE ALL QUESTIONS IF APPLICABLE. ALL INFORMATION IS NEEDED FOR ENLISTMENT.

ADMINISTRATION (LEAD RECORD)

PRIOR SERVICE:YESNOSEX:MALEFEMALE

FULL NAME: ______

LAST FIRST MIDDLE II,JR, ETC

ADDRESS:______

STREET CITY STATE COUNTY ZIP

HOME PH #: ______EMAIL ADDRESS:______

HIGH SCHOOL NAME: ______GRADUATION YEAR: ______

ADMINISTRATION (PREQUALIFICATION)

DOB: ______HEIGHT: ______WEIGHT: ______

HAIR COLOR ______EYE COLOR ______

HIGHEST GRADE COMPLETED: ______MARITAL STATUS: ______

DEPENDENTS: ______

DO YOU HAVE ANY MEDICAL PROBLEMSYESNO

DO YOU HAVE ANY LAW VIOLATIONSYESNO

ARE YOU A US CITIZENYESNO

DO YOU HAVE DUAL CITIZENSHIPYESNO

ADMINISTRATION (PROSPECT RECORD)

SOCIAL SECURITY NUMBER: ______

PLACE OF BIRTH: ______

CITY STATE COUNTY

DRIVERS LICENSE #______EXP DATE______STATE______

RACE: ______ETHNIC CATEGORY: ______

RELIGION: ______

SCREENING (PERSONAL)

ARE YOU MARRIEDYESNO

HAVE YOU EVER BEEN MARRIEDYESNO

ARE YOU LEGALLY SEPARATEDYESNO

HAVE YOU FATHERED/MOTHERED ANY CHILDRENYESNO

IS ANYONE DEPENDENT UPON YOU FOR FINANCIAL SUPPORTYESNO

DO YOU HAVE CUSTODY OF ANY MINOR CHILDRENYESNO

NEGLIGENT IN PROVIDING ALIMONY OR SUPPORT FOR CHILDRENYESNO

HAVE YOU EVER BEEN REJECTED FOR MILITARY SERVICEYESNO

SCREENING (PHYSICAL)

HAVE YOU EVER PROCESSED FOR MILITARY SERVICEYESNO

IF SO WHICH SERVICE______

BACK TROUBLEYESNO

EAR TROUBLE OR LOSS OF HEARINGYESNO

EYE TROUBLE, INJURY, OR ILLNESSYESNO

ANY DEFORMITIES OF, OR MISSING FINGERS OR TOESYESNO

ANY PAINFUL OR TRICK JOINTS OR LOSS OF MOVEMENT IN ANY JOINTYESNO

IMPAIRED USE OF ARMS, LEGS, HANDS AND FEETYESNO

HAVE LOSS OF VISION IN EITHER EYEYESNO

CURRENTLY WEAR BRACES ON YOUR TEETHYESNO

WEAR CONTACT LENSES OR GLASSESYESNO

WEAR A HEARING AIDYESNO

HEPATITISYESNO

RHEUMATIC FEVERYESNO

HAVE YOU EVER BEEN REJECTED FOR MILITARY SERVICEYESNO

DISCHARGED FROM THE MILITARY FOR MENTAL, PHYSICAL OR OTHER REASONSYESNO

RECEIVE OR HAVE YOU APPLIED FOR DISABILITY FROM ANY FEDERAL AGENCYYESNO

TAKEN ANY MEDICATIONSYESNO

BEEN HOSPITALIZEDYESNO

HAD BONES SURGICALLY REPAIRED USING PINS, SCREWS OR PLATESYESNO

DIFFICULTY STANDINGYESNO

HAD A MENTAL CONDITIONYESNO

SLEEPWALKING SINCE AGE 12YESNO

BEEN ADDICTED TO DRUGS OR ALCOHOLYESNO

ALLERGIESYESNO

ASTHMA OR RESPIRATORY PROBLEMSYESNO

BEDWETTER SINCE AGE 12YESNO

EPILEPSY, CONVULSIONS, OR SEIZURESYESNO

OTHER MEDICAL PROBLEMS OR DEFECTS OF ANY KINDYESNO

TATTOOS OR BODY PIERCINGSYESNO

ANY ILLNESS OR INJURYYESNO

Explanation of “yes” answers: Describe problem. Give age at the time of the problem, name of doctor and/or hospital where treated, and your current status regarding the problem.

From______To______Doctor’s Last Name______Age______

Treat Facility______City______St_____Zip______

Describe the Problem: ______

From______To______Doctor’s Last Name______Age______

Treat Facility______City______St_____Zip______

Describe the Problem: ______

From______To______Doctor’s Last Name______Age______

Treat Facility______City______St_____Zip______

Describe the Problem: ______

SCREENING (MORAL/DRUG)

Have you ever been charged with or convicted of any felony offenseYESNO

Have you ever been charged with or convicted of a firearms or explosives offenseYESNO

Do you have/had any court actions of any kindYESNO

Have you ever been charged with or convicted of any offense(s) related to alcohol

or drugsYESNO

Have you ever been subject to court martial or other disciplinary proceedings

under the Uniform Code of Military JusticeYESNO

Have you ever been arrested for, charged with or convicted of any offenseYESNO

Have you been told by anyone that you do not have to list a chargeYESNO

Have you ever possessed/used any illegal drugs (to include Marijuana)YESNO

Have you ever illegally used a controlled substance while immediately affecting the public safetyYESNO

Have you ever been involved in the illegal purchase, manufacture, trafficking, of any illegal drugs (to include Marijuana) for your own intended profit or that of another YES NO

Have you consulted with a mental health professional (psychiatrist, psychologist, counselor, etc.) or have you consulted with another health care provider about a mental health related condition YES NO

Has your use of alcoholic beverages resulted in any alcohol-related treatment or counselingYESNO

Police involvement; including juvenile and minor trafficYESNO

Have you ever been on probation or on early releaseYESNO

Do you have any current or outstanding tickets for parking violationsYESNO

Have you ever been charged with any crime that has not already been claimedYESNO

If you answer yes to any of the MORAL/DRUGS questions, please fill out below.

1. Date______Offense______Disposition______

Who arrested you: Name of Police Dpt______Fined Amount: ______

City______St____County______Zip______

Court______City______St___County______Zip______

2. Date______Offense______Disposition______

Who arrested you: Name of Police Dpt______Fined Amount: ______

City______St____County______Zip______

Court______City______St___County______Zip______

PERSONAL (RESIDENCES)

Working back 10 years. (First, Middle, & Last name of all persons who knew you)

1. FROM______TO: PRESENT STREET______

CITY______ST______COUNTY______ZIP______

PERSON WHO KNEW YOU: NAME______PH#______

STREET______CITY______COUNTY_____ST _____ZIP______

2. FROM______TO: ______STREET______

CITY______ST______COUNTY______ZIP______

PERSON WHO KNEW YOU: NAME______PH#______

STREET______CITY______COUNTY_____ST _____ZIP______

3. FROM______TO: ______STREET______

CITY______ST______COUNTY______ZIP______

PERSON WHO KNEW YOU: NAME______PH#______

STREET______CITY______COUNTY_____ST _____ZIP______

4. FROM______TO: ______STREET______

CITY______ST______COUNTY______ZIP______

PERSON WHO KNEW YOU: NAME______PH#______

STREET______CITY______COUNTY_____ST _____ZIP______

5. FROM______TO: ______STREET______

CITY______ST______COUNTY______ZIP______

PERSON WHO KNEW YOU: NAME______PH#______

STREET______CITY______COUNTY_____ST _____ZIP______

PERSONAL (EMPLOYMENT)(First, Middle, & Last name of all supervisors)

List your employment activities, beginning with the present and working back 10 years.

1. FROM: ______TO:PRESENT EMPLOYER______

YOUR POSTION: ______SUPERVISOR: ______

STREET______CITY______ST____ZIP______

PHONE #______

2. FROM______TO______EMPLOYER______

YOUR POSTION: ______SUPERVISOR: ______

STREET______CITY______ST____ZIP______

PHONE #______

3. FROM______TO______EMPLOYER______

YOUR POSTION: ______SUPERVISOR: ______

STREET______CITY______ST____ZIP______

PHONE #______

4. FROM______TO______EMPLOYER______

YOUR POSTION: ______SUPERVISOR: ______

STREET______CITY______ST____ZIP______

PHONE #______

5. FROM______TO______EMPLOYER______

YOUR POSTION: ______SUPERVISOR: ______

STREET______CITY______ST____ZIP______

PHONE #______

6. FROM______TO______EMPLOYER______

YOUR POSTION: ______SUPERVISOR: ______

STREET______CITY______ST____ZIP______

PHONE #______

PERSONAL (EDUCATION)(First, Middle, & Last name of all persons who knew you)

GRADSENIOROTHER

When did you graduate High School or get your GED Certificate DATE:______

What school? (diploma/GED) ______City______State ______

Do you have any college creditsYESNO

If yes how many hrs______QtrSem

Have you ever been enrolled in ROTCYESNO

Use one of the following codes in the “Code” block:

Codes: 1-High school 2-College 3-Vocational/Tech/Trade

1.FROM: ______TO: ______Code____ Circle: Degree or Diploma or GED

Credit hours_____Circle: Sem or Qtrs hours

School Name______

Street______City______St_____Zip______

Person who knew you:

Last Name______First______Middle______PH#______

Street______City______St_____Zip______

2. FROM: ______TO: ______Code____ Circle: Degree or Diploma or GED

Grad Date______Credit hours_____Circle: Sem or Qtrs hours

School Name______

Street______City______St_____Zip______

Person who knew you:

Last Name______First______Middle______PH#______

Street______City______St_____Zip______

3. FROM: ______TO: ______Code____ Circle: Degree or Diploma or GED

Grad Date______Credit hours_____Circle: Sem or Qtrs hours

School Name______

Street______City______St_____Zip______

Person who knew you:

Last Name______First______Middle______PH#______

Street______City______St_____Zip______

PERSONAL (REFERENCES)(First, Middle, & Last name of all persons who knew you)

List three people who know you well and live in the United States. They should be good friends, peers, colleagues, college roommates, etc. Do not list your spouse, former spouses, or other relatives, and try not to list anyone who is listed elsewhere on this form. Going back10 years.

1. DATES KNOWN:

FROM: ______TO:PRESENT: LAST NAME: ______FIRST:______MI:____

STREET______CITY______ST______ZIP______

PH#______

2. DATES KNOWN:

FROM: ______TO:PRESENT: LAST NAME: ______FIRST:______MI:____

STREET______CITY______ST______ZIP______

PH#______

3. DATES KNOWN:

FROM: ______TO:PRESENT: LAST NAME: ______FIRST:______MI:____

STREET______CITY______ST______ZIP______

PH#______

BACKGROUND (INVESTIGATION RECORD)

Has the United States Government ever investigated your backgroundYESNO

To your knowledge, have you ever had a clearance or access authorization denied, suspended, or revoked, or have you ever been debarred from government employment YES NO

Are you a male born after December 31, 1959YESNO

If yes, have you registered with the Selective Service SystemYESNO

Registration Number______(If known) Legal Exception Explanation______

BACKGROUND (BACKGROUND RECORD)

have you ever been a deserter from any branch of the armed forces of the United StatesYESNO

Have you ever been employed by the United States GovernmentYESNO

Are you now drawing, or do you have an application pending, or approval for: retired pay, disability allowance, severance pay, or pension from any agency of the government of the United States YES NO

Are you now or have you ever been 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 belief or training) YES NO

Have you ever been discharged by any branch of the Armed Forces of the United States for reasons pertaining to being a conscientious objector YES NO

Is there anything which would preclude you from performing military duties or participating in military activities whenever necessary (i.e., do you have any personal restrictions or religious practices which would restrict your availability

YESNO

Have you ever been an officer or a member or made a contribution to an organization dedicated to the violent overthrow of the United States Government and which engages In illegal activities to that end, knowing that the organizations engages in such activities With the specific intent to further such activities YES NO

Have you ever knowingly engaged in any acts or activities designed to overthrow the United States Government by force YES NO

Have you ever applied and not been selected for ROTCYESNO

Have you ever applied and not been selected for OCSYESNO

Have you ever applied and not been selected for appointment in Reserve component (USAR/ARNG) as a warrant officer YES NO

Have you ever applied and not been selected for appointment in Reserve component (USAR/ARNG) as a commissioned officer YES NO

Have you ever applied and not been selected for appointment in Regular Army as a warrant officerYESNO

Have you ever applied and not been selected for appointment in Regular Army as a commissioned officer YES NO

Have you ever resigned or been asked to resign in lieu of elimination proceedings; been discharged in lieu of elimination, furloughed, or placed on inactive status while serving in the US Armed Forces; or, have you ever resigned or been asked to resign from position while in government or private employment YES NO

Yes answers, Explain______

BACKGROUND (FINANCIAL RECORD)

Have you filed a petition under any chapter of the bankruptcy codeYESNO

Have you had your wages garnished or had any property repossessed for any reasonYESNO

Have you had a lien placed against your property for failing to pay taxes or other debtsYESNO

Have you had any judgements against you that have not been paidYESNO

Is there any court order or judgement in effect that directs you to provide alimonyYESNO

Have you been over 180 days delinquent on any debt(s)YESNO

Are you currently over 90 days delinquent on any debt(s)YESNO

If you answered yes to the questions above, please provide the information requested below.

Incurred Date______Satisfied______Amount______

Type of Action/Loan______Name______

Address: ______City______ST______Zip______

BACKGROUND (FOREIGN ACTIVITES)

Do you have foreign property, business connections, or financial interestsYESNO

Are you now or have you ever been employed by or acted as a consultant for a foreign government, firm, or agency YES NO

Have you ever had any contact with a foreign government, its establishments (embassies or consulates), or it’s representatives, whether inside or outside the U.S., other than on official U.S. Government business? (Does not include routine visa applications and border crossing contacts.) YES NO

In the past 7 years, have you had an active passport that was issued by a foreign Government?YESNO

List foreign countries you have visited, except on travel under official Government orders, beginning with the most current and working back 7 years. (Travel as a dependent or contractor must be listed.)

Include short trips to Canada or Mexico. If you have lived near a border and have made short (one day or less) trips to the neighboring country, you do not need to list each trip. Instead, provide the time period, the country, and a note (“Many Short Trips”).

Do not repeat travel that is listed as residence, employment, or education.

From______To______Purpose of Visit______Country______

FAMILY (FAMILY AND ASSOCIATES)(First, Middle, & Last name of all persons who knew you)

Give the full name, correct code, and other requested information for each of your relatives and associates, living or dead, specified below.

1-Mother(first) / 5-Foster parent / 9-Sister / 13-Half-sister / 17-Other Relatives
2-Father (second) / 6-Child (adopted also) / 10-Stepbrother / 14-Father-in-law / 18-Associate
3-Stepmother / 7-Stepchild / 11-Stepsister / 15-Mother-in-law / 19-Adult Currently living with you
4-Stepfather / 8-Brother / 12-Half-brother / 16-Guardian living with you

YOUR MOTHER’S MAIDEN NAME______

DATE OF MARRIAGE: ______

FULL Name- include middle name(If deceased, check box on the left before entering name) / Code / Date of Birth
YY/MM/DD / City State of Birth / Country(ies) of Citizenship / Current Street Address and City (country) of Living Relatives / State
ZIP
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2

DO you elect to purchase the SGLI (Serviceman’s Group Life Insurance)

of $400, 000 for $29.00 per month? If so, who will be the beneficiary?

YES / NO

NAME______SSN______-______-______

ADDRESS______

CITY______ST______ZIP______

PHONE______RELATIONSHIP______

FAMILY (YOUR SPOUSE)

  1. CURRENT SPOUSE. Complete the following about your current spouse only.

Last Name______First Name______Middle______

SSN: ______Citizenship______DOB______

Place of Birth:City______County______ST: ____

Address if different from yours: Street______

City______St______County______Zip______

PH#______Is your spouse now or have ever been in the Military YES NO

Date Married: ______Place Married:City______St______

County______

FAMILY (FORMER SPOUSE)

Last Name______First______Middle______

Date of Birth______Place of Birth______St______

Country(ies) of Citizenship______Date Married______

Place Married (Include country if outside the U.S.)______St______

Divorced/Widowed (circle one) YY/MM/DD______

If divorced, where is the record located? City (Country)______St______

Address of Former Spouse: Street______City______

St______County______Zip______

Telephone Number______

BANK ACCOUNT INFO

* If you do not have an account, use your parents account and you can change account later *

Bank Name: ______Phone #______

Address: ______

Account Type: Checking ______Savings ______

Account Number: ______

Routing Number: ______

************************************************************************************

I hereby certify that the above information is true and correct to the best of my knowledge. No one has influenced me to give any untrue or misleading answers or statements.

Signature:______Date:______

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