Information Furnished By Name


Phone Number (for verification)


Email Address (for verification)


Enlistee Information First Name


Last Name


Parent Name(s)


Rank


Branch of Service


Address


Address (line 2)


City


State


Zip Code


Phone Number




When (if recently) was basic training completed?
(mm/dd/yyyy)

Where was basic training completed?


List recent training and station locations


Will report where, when, for what duty or school




Marital Status


Spouses name and address (if applicable)


Names of children (if applicable)




Education (if applicable)


Graduation date
(mm/dd/yyyy)

Enlistment date
(mm/dd/yyyy)

Left for basic training
(mm/dd/yyyy)

You will have an opporutunity to submit a photo of the enlisted after submitting this form.