PUERTO RICO NATIONAL GUARD

STATE COMMAND

REQUISITOS DE INGRESO EN LA GUARDIA ESTATAL DE PUERTO RICO

- ENLISTADO1. 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 EQUIVALENTE.
9. EXAMEN MDICO POR UN MDICO DE VETERANOS, GUARDIA NACIONAL O GUARDIA ESTATAL.
10. ANLISIS DE SANGRE, ORINA, ETC.
11. TIPO DE SANGRE
12. FORMA 2006
13. (1) FOTOGRAFA
14. ENTREVISTA POR EL COMANDANTE DE LA UNIDAD A INGRESAR Y TRAER PRRAFO Y LNEA
DE LA POSICIN DISPONIBLE PARA INGRESO.
15. CERTIFICACIN 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 AOS 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

ENLISTMENT RECORD
SECTION I - APPLICATION FOR ENLISTMENT

1. NAME OF APPLICANT

(Last name,

3. CURENT MAIL ADDRESS

(Include zip code)

5. P. R. STATE GUARD UNIT

(Company and Battalion)

first name

2. SERVICE NUMBER (Social Security)

middle name)

4. FORMER MILITARYSERVICE NUMBER (S)

8. CITIZENSHIP

6. INITIAL ASSIGNMENT

7. GRADE

9. DATE OF BIRTH

11. HEIGHT

12. WEIGHT

17. CONDITION OF HEALTH

13. COLOR OF EYES

18. MARITAL STATUS

14. COLOR OF HAIR

15. COMPLEXION

16. IDENTIFYING MARK/SCARS

19. NAME OF SPOUSE (Include first name and maiden name)

20. NAME AND ADDRESS OF PRESENT EMPLOYER OR FIRM

23. HEVE YOU EVER BEEN CONVICTED OF A FELONY?

10. PLACE OF BIRTH

21. YOUR JOB TITLE

22. HOW LONG IN PRESENT JOB

(Submit report of Good Conduct with Application)

24. CIVILIAN EDUCATION (List high schools, trade schools, colleges, and universities attended)
Name of School

Location (City & State)

Graduated?

Year

Degree or Rating Awarded

25. PRIOR MILITARY SERVICE (List each tour of duty, promotion, transfer, duty assignment and unit)
Date From

Date To

Grade

Armed Force

Branch

Duty Assignment

Unit and Station (Location)

26. SERVICE MEDALS, COMMENDATIONS, CITATIONS AND DECORATIONS AWARDED

27. MILITARY SCHOOLS COMPLETED

Name of Course

Name of Service School and Location

Year Completed

Qualification Awarded

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.

_____________________________
DATE OF ENLISTMENT
- PRSG - FORM 104 - FOR COL APPROVAL - 08/2008

_______________________________________________________
SIGNATURE OF VOLUNTEER
Page-1

SECTION II - CERTIFICATION BY UNIT COMMANDER

29.

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)

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)
SECTION III - OATH OF ENLISTMENT

30.

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.
______________________________________
SIGNATURE

Subscribed and sworn before me at ______________________ , Puerto Rico, on this ________ day of ____________ 20____.

______________________________________________
(SIGNATURE OF OFFICER ADMINISTERING OATH)

_______________________________________
(PRINTED NAME AND GRADE)
31.

SECTION IV - IDENTIFICATION CARD REGISTER

Initial issue of Puerto Rico State Guard Identification Card # _________________________ on _________________________ .
Above numbered Identification Card was reissued on the following dates:
______________
32.

______________

______________

______________

______________

SECTION V - RECORD OF AWARDS AND DECORATIONS NOT PREVIOUSLY RECORDED

AWARD

33.

EFFECTIVE DATE

PERMANENT ORDERS NUMBER & DATE

SECTION VI - SERVICE RECORD SUBSEQUENT TO ENLISTMENT

EFFECTIVE DATE

GRADE

DUTY ASSIGNMENT

34.
To:

______________

P. R. STATE GUARD UNIT

ORDERS NUMBER & DATE

SECTION VII - FINAL ENDORSEMENT FOR DISCHARGE

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 _____________________________________________.

______________________________________________
SIGNATURE OF COMMANDING OFFICER

Page-2

LAST NAME

SSAN

OTHER BACKGROUND DATA

MEMBERSHIP IN YOUTH PROGRAMS

1.

NO

YES

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
2.

DECLARATIONS
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. 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).

3.

UDERSTANDINGS

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.

4.

INITIALS

CARACTER AND SOCIAL ADJUSTMENT

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
APPLICANT HAS BEEN INTERVIEWED AND IS

ELEGIBLE FOR ENLISTMENT

DATE OF INTERVIEW

GRADE, NAME, ORG & TITLE OF

INELEGIBLE FOR ENLISTMENT

COMMANDER

SIGNATURE OF COMMANDER
Page-3

7. ______________________________, _________________________, __________________ ________-______-________ (

) (CLOSEST NEX OF KIN NAME)
(LAST NAME)
(FIRST) (MI)
(SSN)
(HOME PHONE NO.)

) (CELL PHONE NO.)

) (CELL PHONE NO.)

____________________________________________________________
SERVICE MEMBER SIGNATURE
____________________________________________________________
PRSG FORM 107 (Revised 16 May 2005)

(ADITIONAL INFORMATION USE BACK OF FORM)

____________________________________________________________
DATE SIGNED
Page-4

______________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________

9. PERSON TO NOTIFY IN CASE OF EMERGANCY (PLEASE CLEARLY PRINT ADDRESS AND TELEPHONES IN SPACE BELOW)

8. _______________________________________________________________________, ____________________________, _____________________, __________, _______________

(TOWN)
(HOME ADDRESS)
(CITY)
(STATE)
(ZIP CODE)

6. ______________________________, _________________________, __________________ ________-______-________ (

) (SPOUSE NAME)
(LAST NAME)
(FIRST) (MI)
(SSN)
(HOME PHONE NO.)

5. _______________________________________________________________________, ____________________________, _____________________, __________, _______________

(POSTAL ADDRESS)
(TOWN)
(CITY)
(STATE)
(ZIP CODE)

4. _______________________________________________________________________, ____________________________, _____________________, __________, _______________

(HOME ADDRESS)
(TOWN)
(CITY)
(STATE)
(ZIP CODE)

1. ______________________________, _________________________, __________________ 2. ________-______-________ 3. _______________, ___________, __________________

(NAME)
(LAST NAME)
(FIRST) (MI)
(SSN)
(GROUP)
(BN)
(COMPANY)

EMERGENCY DATA CARD

San Juan, Puerto Rico 00902-3786

PUERTO RICO STATE GUARD

HEADQUARTERS

MILITARY FORCES OF PUERTO RICO

____________________
UNIT

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).

________________________________
Signature
________________________________
SSN

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MEDICAL RECORD

DATE OF EXAM

REPORT OF MEDICAL EXAMINATION

1. LAST NAME - FIRST NAME - MIDDLE NAME

2. IDENTIFICATION NUMBER

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

9. RELATIONSHIP OF CONTACT

7. AGE

8. SEX
FEMALE

10. PLACE OF BIRTH

3. GRADE AND COMPONENT OR POSITION

MALE

11. RACE
WHITE

12a. AGENCY

AMERICAN INDIAN/
ALASKA NATIVE

BLACK

HISPANIC
HISPANIC
ASIAN/PACIFIC
WHITE
BLACK
ISLANDER
13. TOTAL YEARS GOVERNMENT SERVICE

12b. ORGANIZATION UNIT

a. MILITARY
14. NAME OF EXAMINING FACILITY OR EXAMINER, AND ADDRESS

b. CIVILIAN

15. RATING OR SPECIALTY OF EXAMINER

16. PURPOSE OF EXAMINATION

17. CLINICAL EVALUATION

NORMAL

ABNOR- NORMAL
MAL

(Check each item in appropriate column, enter "NE" if not evaluated.)

(Check each item in appropriate column, enter "NE" if not evaluated.)

A. HEAD, FACE, NECK AND SCALP

O. PROSTATE (Over 40 or clinically indicated)

B. EARS - GENERAL (INTERNAL CANALS)

(Auditory acuity under items 39 and 40)

P. TESTICULAR

C. DRUMS (Perforation)

R. ENDOCRINE SYSTEM

D. NOSE

S. G-U SYSTEM

E. SINUSES

T. UPPER EXTREMITIES (Strength, range of motion)

F. MOUTH AND THROAT

U. FEET

G. EYES - GENERAL (Visual acuity and refraction under items 28, 29, and 36)

V. LOWER EXTREMITIES (Except feet) (Strength, range of motion)

H. OPTHALMOSCOPIC

W. SPINE, OTHER MUSCULOSKELETAL

I. PUPILS (Equality and reaction)

X. IDENTIFYING BODY MARKS, SCARS, TATTOOS

J. OCULAR MOTILITY (Associated parallel movements nystagmus)

Y. SKIN, LYMPHATICS

K. LUNGS AND CHEST

Z. NEUROLOGIC (Equilibrium tests under item 41)

L. HEART (Thrust, size, rhythm, sounds)

AA. PSYCHIATRIC (Specify any personality deviation)

M. VASCULAR SYSTEM (Varicosities, etc.)

BB. BREASTS

N. ABDOMEN AND VISCERA (Include hernia)

ABNORMAL

CC. PELVIC (Females only)

Q. ANUS AND RECTUM (Hemorrhoids, Fistulae) (Hemocult Results)

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.)
0
1 2
3
32 31 30
0

R
I
G
H
T

1
32

/
1 2
3
32 31 30
/

Restorable
Teeth

2
31

3
30

4
29

5
28

Nonrestorable
Teeth

6
27

7
26

X
1 2
3
32 31 30
X

8
25

9
24

X X X Replaced
1 2
3
by
32 31 30 Dentures
X X X

Missing
Teeth

10
23

11
22

12
21

13
20

14
19

(
X
)
1 2
3
32 31 30
(
X
)

15
18

16
17

Fixed
Partial
Dentures

REMARKS AND ADDITIONAL DENTAL

DEFECTS AND DISEASES

L
E
F
T

19. TEST RESULTS (Copies of results are preferred as attachments)

B. CHEST X-RAY OR PPD (Place, date, film number and result)

A. URINALYSIS: (1) SPECIFIC GRAVITY

(2) URINE ALBUMIN

(4) MICROSCOPIC

(3) URINE SUGAR

C. SYPHILIS SEROLOGY (Specify test used
and results)

D. EKG

NSN 7540-00-634-4038
88-126
Designed using Perform Pro, WHS/DIOR, Jan 97

E. BLOOD TYPE AND RH F. OTHER TESTS

FACTOR

STANDARD FORM 88 (Rev. 10-94) (EG)

Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1

NAME

IDENTIFICATION NUMBER

NO. OF SHEETS ATTACHED

MEASUREMENTS AND OTHER FINDINGS

20. HEIGHT

21. WEIGHT

22. COLOR HAIR

23. COLOR EYES

24. BUILD
SLENDER

26. BLOOD PRESSURE (Arm at heart level)

B.
C.
SYS.
SYS.
SYS.
A.
RECUMSTANDING
SITTING DIAS.
BENT
DIAS.
(5 mins.) DIAS.
28. DISTANT VISION

EXO

OBESE

30. NEAR VISION

S.

CX

CORR. TO

BY

BY

S.

CX

CORR. TO

BY

R.H.

L.H.

PRISM DIV.

PRISM CONV.
CT

PC

33. COLOR VISION (Test used and result)

34. DEPTH PERCEPTION

(Test used and score)

36. NIGHT VISION (Test used and score)

32. ACCOMMODATION
RIGHT

B. RECUMBENT

HEAVY

27. PULSE (Arm at heart level)

C. STANDING D. AFTER EXERCISE E. 2 MINS. AFTER
(3 mins)

BY

LEFT 20/
CORR. TO 20/
31. HETEROPHORIA (Specify distance)
ESO

MEDIUM

29. REFRACTION

CORR. TO 20/

RIGNT 20/

A. SITTING

25. TEMPERATURE

37. RED LENS TEST

UNCORRECTED

LEFT

CORRECTED

35. FIELD OF VISION

RIGHT

PD

38. INTRAOCULAR TENSION

LEFT

RIGHT

39. HEARING

40. AUDIOMETER

RIGHT W/V

/15SV

/15

LEFT W/V

/15SV

/15

250
256

500
512

LEFT

41. PSYCHOLOGICAL AND PSYCHOMOTOR (Tests used and score)

1000 2000 3000 4000 6000 8000

1024 2048 2896 4096 6144 8192

RIGHT
LEFT

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

U

P
46. EXAMINEE (Check)
A.
IS QUALIFIED FOR
B.

45B. PHYSICAL CATEGORY

IS NOT QUALIFIED FOR

47. IF NOT QUALIFIED, LIST DISQUALIFYING DEFECTS BY ITEM NUMBER

48. TYPED OR PRINTED NAME OF PHYSICIAN

SIGNATURE

50. TYPED OR PRINTED NAME OF DENTIST OR PHYSICIAN (Indicate which)

SIGNATURE

49. TYPED OR PRINTED NAME OF PHYSICIAN

SIGNATURE

51. TYPED OR PRINTED NAME OF REVIEWING OFFICER OR APPROVING AUTHORITY SIGNATURE

STANDARD FORM 88 (Rev. 10-94) BACK

MEDICAL RECORD

REPORT OF MEDICAL HISTORY

NO. OF ATTACHED SHEETS:

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)
4a. HOME STREET ADDRESS (Street or RFD; City or Town; State; and ZIP Code)

3. GRADE

2. IDENTIFICATION NUMBER
5. EXAMINING FACILITY

4b. CITY

4c. STATE

4d. ZIP CODE

6. PURPOSE OF EXAMINATION

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.

c. ALLERGIES (Include insect bites/stings and common foods)

d. HEIGHT

e. WEIGHT

9. ARE YOU (Check one)

8. PATIENT'S OCCUPATION

RIGHT HANDED

LEFT HANDED

10. PAST/CURRENT MEDICAL HISTORY

CHECK EACH ITEM

YES

NO

DON'T
KNOW

CHECK EACH ITEM

YES

NO

DON'T
KNOW

CHECK EACH ITEM

Household contact with anyone

with tuberculosis

Shortness of breath
Chronic cough

Blood in sputum or when

coughing

Palpitation or pounding heart

Painful or "trick" shoulder

or elbow

Excessive bleeding after injury or

dental work

High or low blood pressure

Recurrent back pain or any

back injury

Cramps in your legs

"Trick" or locked knee

Suicide attempt or plans

Frequent indigestion

Foot trouble

Sleepwalking

Stomach, liver or intestinal trouble

Nerve Injury

Wear corrective lenses

Gall bladder trouble or

gallstones

Paralysis (including infantile)

Eye surgery to correct vision

Lack vision in either eye

Jaundice or hepatitis

Car, train, sea or air sickness

Wear a hearing aid

Broken bones

Frequent trouble sleeping

Stutter or stammer

Adverse reaction to medication

Depression or excessive worry

Wear a brace or back support

Skin diseases

Loss of memory or amnesia

Scarlet fever

Tumor, growth, cyst, cancer

Nervous trouble of any sort

Rheumatic fever

Hernia

Periods of unconsciousness

Swollen or painful joints

Hemorrhoids or rectal disease

Frequent or severe headaches

Frequent or painful urination

Parent/sibling with diabetes,

cancer, stroke or heart disease

Dizziness or fainting spells

Bed wetting since age 12

X-ray or other radiation therapy

Eye trouble

Kidney stone or blood in urine

Chemotherapy

Hearing loss

Sugar or albumin in urine

Recurrent ear infections

Sexually transmitted diseases

Asbestos or toxic chemical

exposure

Chronic or frequent colds

Recent gain or loss of weight

Plate, pin or rod in any bone

Severe tooth or gum trouble

Eating disorder (anorexia bulimia,

etc.)

DON'T
KNOW

Loss of finger or toe

Tuberculosis or positive TB test

NO

Bone, joint or other deformity

Pain or pressure in chest

YES

Easy fatigability

Sinusitis
Hay fever or allergic rhinitis

Heart trouble

Head injury

Arthritis, Rheumatism, or
Bursitis

Asthma

Thyroid trouble or goiter

NSN 7540-00-181-8368
Previous edition not usable

Epilepsy or seizure

Been told to cut down or

criticized for alcohol use
Used illegal substances
Used tobacco

STANDARD FORM 93

(REV. 6-96)
Prescribed by ICMR/GSA
FIRMR (41 CFR) 201-9.202-1

CHECK EACH ITEM

YES

NO

11. FEMALES ONLY

DON'T DATE OF LAST MENSTRUAL DATE OF LAST PAP SMEAR
KNOW PERIOD

DATE OF LAST MAMMOGRAM

Treated for a female disorder

Change in menstrual pattern
CHECK EACH ITEM. IF "YES" EXPLAIN IN BLANK SPACE TO RIGHT. LIST EXPLANATION BY ITEM NUMBER.
ITEM

YES

NO

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.)
23. LIST ALL IMMUNIZATIONS RECEIVED
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.
24a. TYPED OR PRINTED NAME OF EXAMINEE

24b. SIGNATURE

24c. DATE

NOTE: HAND TO THE DOCTOR OR NURSE, OR IF MAILED MARK ENVELOPE "TO BE OPENED BY MEDICAL OFFICER ONLY".
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.)

26a. TYPED OR PRINTED NAME OF PHYSICIAN OR EXAMINER

26b. SIGNATURE

26c. DATE

STANDARD FORM 93

(REV. 6-96)

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