COAST GUARD APPLICATION U.S. Coast Guard Recruiting 8109-F NE Vancouver Mall Dr Vancouver, WA 98662 PHONE: (360) 699-1045 FAX: (360) 699-1048

Coast Guard and Coast Guard Reserve

Thank you for your interest in the United States Coast Guard. To get all the facts on educational opportunities, adventure and excitement, please fill out this application and mail or fax it to the Coast Guard Recruiting Office at the address listed above. This information will only be used by your local recruiter to determine your eligibility and it does not obligate you to join. Your personal information is not shared with any person(s) and/or agency outside of the Coast Guard without your consent. We will not schedule an appointment without a complete application on file. Applicant Information Last Name

First Name

Middle Name

Maiden Name

Street Address

Apartment/Unit #

City

County

State

Home Phone

Cell Phone

(

(

)

Social Security Number

Country

E-mail

)

Drivers License Number

Date of Birth

Zip

State Issued

Expiration Date

Age

Gender

MALE

FEMALE

Place of Birth City

State

Country

U.S.

Citizenship (check all that apply)

U.S. at Birth (Check one below) Native Born Born Abroad of U.S. Parents

Lawful Permanent Resident (Check one below) Other U.S. Naturalized Immigrant Alien: Alien Registration Number: _____________________

Race or Population Group (check all that apply)

American Indian/Alaskan Native White/Caucasian Other

Hawaiian/Pacific Islander Asian

Black or African American Multi-Racial

Not Hispanic or Latino

Decline to Respond/Other

Ethnic Category (check one)

Hispanic or Latino Marital Status

Single

Married

Divorced

Separated

Widowed

# of Children:

Education Education Level (check all that apply)

Currently in High School

Last FULL year of High School Completed?

9

10

11

12

GED

High School Diploma

Non-traditional H.S. Diploma

Currently in College

Associates Degree

Baccalaureate Degree

Master’s Degree YES NO YES NO

Other Degree

Total College Credits Obtained: ____________

Have you ever been in ROTC, JROTC, Sea Cadets, or Civil Air Patrol? # of Years ______ Have you received the Boy Scouts’ Eagle Scout Award or Girl Scouts’ Gold Award?

Other Information YES YES

NO NO

Have you ever taken the ASVAB or signed any paperwork with a different Armed Service?

YES

NO

Have you ever been rejected for enlistment/commission into any branch of the Armed Services?

YES YES

NO NO

Are you now, or have you ever been, a conscientious objector?

YES

NO

Please Use Tattoo Form Do you have any tattoos? Explain: _______________________________________________________________

YES

NO

Have you every used or experimented with any illegal drugs (including marijuana)?

Can you swim? If not, can you be taught to swim? * Swimming ability is not required, the ability to learn is.

Have you ever filed for Bankruptcy?

How many times?

Program interested in:

Full-Time Enlisted

Age of last use?

Date of last use?

Part-Time Reserve

Officer Programs (requires college degree)

MEDICAL SCREENING

Name: __________________________________________ HAVE YOU EVER HAD, OR DO YOU NOW HAVE (CHECK ALL THAT APPLY): Answer truthfully; checking any box does not automatically disqualify you from service.

Asthma, weezing, or inhaler use Dislocated joint Epilepsy, fits, seizures, or convulsions Sleepwalking Recurrent neck or back pain Rheumatic fever Foot pain A swollen, painful or fluid in a joint Double vision Periods of unconsciousness Frequent or severe headaches Wear contact lenses Fainting spells or passing out Head injury Back surgery Seen a psychologist, psychiatrist, social worker, counselor or other professional for any reason including counseling or treatment for school, adjustment, family, marriage or other problem, including depression, treatment for alcohol or substance abuse. Skin disease (eczema, psoriasis, atopic dermatitis) Irregular, rapid or slow heartbeat Allergic to bee, wasp, or insect stings Heart murmur or heart valve problem Allergic to wool Heart Surgery Been rejected for military service for medical reasons Pain or swelling at the site of an old fracture Perforated ear drum or tubes in ear drums Anemia Ear surgery Night blindness Arthritis Absence or the disturbance of smell Absence, removal, rupture or tear of the spleen Anorexia or other eating disorder Cracked bone or fracture Bursitis Do you currently wear braces or under the care of an Orthodontist? Loss of fingers or toes Loss of the ability to fully flex a finger, toe or other joint Any medical condition not listed above

Any other heart problems High blood pressure Discharged from military service for medical reasons Ulcer Received disability compensation Hepatitis Intestinal obstruction or other intestinal problem Detached retina Surgery to remove a portion of the intestine Any eye condition, injury or surgery Are you over 40 Gall bladder trouble or gall stones Jaundice Missing a kidney Allergy to common food (females) Abnormal PAP or other gynecological problem (Males) Missing a testicle, testicular implant, or undescended testicle Broken bone requiring surgery to repair (pins, screws, plates) Ruptured or bulging disk in or back or surgery Thyroid condition or medication for thyroid Limited motion of any joint Drug or alcohol rehab Kidney, urinary tract or bladder problems, surgery, stones, Or other urinary tract problems Sugar, protein, or blood in urine Surgery on a bone or joint, including arthroscopy Currently taking any medications Shoulder, knee, or elbow problem (out of place) Locking of the knee or other joint Giving way of the knee or other joint Cataracts or surgery for cataracts Eye surgery Collapsed lung or other lung condition Bedwetting since the age of 12 Evaluation, treatment, or hospitalization for alcohol abuse, dependence, or addiction Taken any medication or substance to improve attention behavior, or physical performance Do you smoke How many per day _________ Date last used __________ Evaluation and/or treatment for substance abuse

Height: _______ Weight: _______ *Wrist Size: ______ *If you have a tape measure, wrap it around the wrist of your dominant hand where there are two knobs. The tape should be snug, but not compress the skin.

EXPLAIN ALL ITEMS CHECKED ABOVE (Describe the condition, dates, treatment given, and current medical status):

Attach additional pages if necessary

Military Service Branch

Years of Active Duty

Date From

Date To

Rank

Type of Discharge (RE Code on DD-214)

Years of Active Duty

Date From

Date To

Rank

Type of Discharge (RE Code on DD-214)

NONE Branch

If other than honorable discharge, please explain:

Police Record YES

NO

Have you ever been charged or convicted of a felony?

If yes, please explain:

List all other traffic, civil, or criminal violations: Date Violation

County/State

Resolution (i.e. dropped, paid fine, etc.)

Financial Obligations YES

NO

Do you currently live with your parents?

Amount of monthly rent or mortgage: $____________ List all financial obligations (such as loans and credit cards – not monthly utility /phone bills): Name of Company For What Total Owed

YES

NO

Have you ever filed for Bankruptcy?

Minimum Monthly Payment

When? _______________

* NOTE: If you are over 90 days delinquent on any debts, get current or obtain a payment plan before submitting this application. We cannot enlist or commission anyone who is not up to date on their bills. Previous testing and physicals Have you ever taken the ASVAB?

YES

NO

Previous MEPS physical?

YES

NO

OFFICER APPLICANTS:

Where?

AFQT

Where?

Date

Date

ACT Score: _____ SAT Score: _____ Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. Signature

Date

Please fill out and sign the attached “Tattoo Screening Form” and mail with this application to:

Recruiter in Charge Coast Guard Recruiting 8109-F NE Vancouver Mall Dr Vancouver, WA 98662

or fax to (360) 699-1048

If you have any questions regarding this application or the attached forms, please call (360) 699-1045.

Encl. (4) to COMDTINST 1001.1A TATTOO SCREENING FORM, CG-6052 (1-05) Privacy Act Statement AUTHORITY: Collection of this information is authorized per 10 USC, sections 503, 505, 12102, and Executive Order 9397 PRINCIPAL PURPOSE: Information collected will be used to assist in the qualification process ROUTINE USES: Blanket routine use of disclosures as described in CIM 1020.6 (series) and CI 1000.1A. DISCLOSURE: Voluntary, however, failure to provide the information may delay the enlistment process or initiate action for discharge.

APPLICANT/MEMBER NAME:

SSN:

Mark all tattoos, brands, body piercing, intentional scarring, or mutilations on the above diagram with a number and describe below.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. APPROVED: DISAPPROVED:

UNIT:

SIGNATURE:

DATE: