Your Interest: CHOOSE RESERVE ACTIVE




Full Name:

Email address:

Street Address:

City:     State:

Zip Code:   D.O.B. (YYYYMMDD)

Sex: choose one MALE FEMALE   Age: choose one 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39

Height: FEET 4 FEET 5 FEET 6 FEET   INCHES 0 INCH 1 INCH 2 INCHES 3 INCHES 4 INCHES 5 INCHES 6 INCHES 7 INCHES 8 INCHES 9 INCHES 10 INCHES 11 INCHES    Weight:

Marital Status: choose one SINGLE MARRIED DIVORCED Are you a Single Parent? choose one Yes No

# of Dependents (this includes your spouse)  

Home phone:    (include area code)

Cell phone:    (include area code)

Are you Prior Service? choose one Yes No What Branch? choose one U.S. Navy U.S. Marine Corps U.S. Air Force U.S. Army U.S. Coast Guard National Guard

Active or Reserve? choose one Active Reserve IRR Status   How many years? choose one 1-4 years 5-8 years 9-12 years 13-17 years

Explain why you got out or if you are in the IRR & still under contract:

Do you have any past or present police involvement? (ie. tickets, felonies)
choose one Yes No All Yes Responses must be explained below.
Explain police issues below:

Do you have any past or present medical issues? (ie. broken bones, asthma)
choose one Yes No All Yes Responses must be explained below.
Explain medical issues below:

Do you have any past or present drug issues? (ie. marijuana, drug addictions )
choose one Yes No All Yes Responses must be explained below.
Explain drug issues below:

Do you have any past or present mental issues? (ie. depression, suicidal)
choose one Yes No All Yes Responses must be explained below.
Explain mental issues below:

Do you have any tattoos?  choose one Yes No How many? choose one NONE 1-2 3-4 5-6 7 +
What & Where?
1. 2. 3. 4. 5.

Do you have Gold Teeth? choose one Yes No

Do you have a Diploma or a GED? choose one DIPLOMA GED   Year?

Have you worked within the past 12 months? choose one Yes No

What is your current job? and what do you do? How long?

Are you currently attending College? choose one Yes No

Do you have a Degree? choose one Yes No Degree:

Do you have transportation? choose one Yes No

How did you hear about this website?  choose one WORD OF MOUTH BUSINESS CARD OTHER

Any additional information: