Fillable Printable Application For Appointment

Application For Appointment

PERSONAL DATA

Title 10 United States Code, Section 3012 (Title 5 United States Code, Section 552a)

Disclosure of information requested in DA Form 61 is voluntary. Failure to provide the required information will result in non-acceptability of the application.

APPLICATION FOR APPOINTMENT

For use of this form, see AR 135-100, AR 145-1, AR 351-5, and AR 601-100; the proponent agency is DCSPER

DATA REQUIRED BY THE PRIVACY ACT OF 1974

AUTHORITY:

PRINCIPAL PURPOSE:

ROUTINE USES:

DISCLOSURE

Regular Army and Officer Candidate applicants and all ROTC graduates:

In numerical sequence, indicate 10 branch preferences other than CA and SS.

branch of the vacant position; all other applicants may enter more than one branch.

PREFER-

ENCE

a. NAME OF SCHOOL

23a. FOREIGN LANGUAGES AND DEGREE OF PROFICIENCY

DATE DESIGNATED:

SCHOLARSHIP - ENTER 1, 2, 3 OR 4 YEARS:

DMG

a. MOS CODE b. MOS TITLE

BRANCH SPECIALTY

10. BRANCH

(MOS if enl or wo)

a. HIGH SCHOOL GRADUATE

c. NAME AND LOCATION OF EACH COLLEGE

OR UNIVERSITY ATTENDED (Include USMA,

USNA, USAFA, USCGA, and USMMA)

9a. SOCIAL SECURITY NUMBER

9b. SELECTIVE SERVICE NUMBER

16. SEX

8. GRADE

11. TOTAL YRS

ACTIVE SERVICE

b. NAME AND LOCATION OF HIGH SCHOOL

d. IF NOT COMPLETED GIVE REASON

TO YES NOFROM

COMPLETED

b. COURSE

20. US

CITIZEN

a. NATIVE

DAY MONTH YEAR

COMMISSIONED OFFICER - REGULAR ARMY

COMMISSIONED OFFICER - ARMY RESERVE

WARRANT OFFICER - REGULAR ARMY

WARRANT OFFICER - ARMY RESERVE

OFFICER CANDIDATE SCHOOL

YES

NATURALIZATION

DERIVED

IMMIGRANT

YES

PHONE AND/OR DSN NUMBER

NOYES

DA FORM 61, JUN 1981

EDITION OF 1 AUG 74 AND DA FORM 61-R, 26 SEP 75, PRIVACY ACT STATEMENT, ARE OBSOLETE.

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22.

HIGHEST LEVEL SERVICE SCHOOL ATTENDED

c. APPLICANT'S CERTIFICATE NO. (If Item b. checked) (Date, place, court)

17. COMPLETE MILITARY ADDRESS (If presently on active duty) (Include ZIP Code)

19. CURRENT MAILING ADDRESS (If difference from Item 18) (Include ZIP Code)

USAR applicants: If applying for a specific Reserve vacancy, indicate

ONLY

the

1. TYPE OF APPOINTMENT FOR WHICH APPLICATION IS SUBMITTED

BRANCH AND SPECIALTY PREFERENCES

2. GOVERNING REGULATION OR CIRCULAR (Specify appropriate section(s) if applicable)

3. GRADE FOR WHICH APPLYING (Reserve appointments only)

4. SOURCE OF APPLICATION (ROTC only)

5. ONLY FOR APPLICANTS FOR APPOINTMENT AS WARRANT OFFICERS

(List choice by MOS code and title)

7. NAME (Last, first, middle)(Explain variations from birth certificate in Item 41)

15. PLACE OF BIRTH (City, county,

state)

21. CIVILIAN EDUCATION (See page 3 for additional requirements for professional personnel)

18. PERMANENT ADDRESS

(Include ZIP Code)

(1)

DEGREE

(2)

SEMESTER

CREDITS

EARNED

(3)

YEARS

ATTENDED

(4)

DATE GRADUATED

OR WILL GRADUATE

(5)

MAJOR

SUBJECT

b. ALAT SCORE (If applicable)

c. DATES (Mo-Yr)

PHONE

(Include area code)

PHONE (Include area code)

d. SPECIAL EDUCATIONAL HONORS, SCHOLAR-

SHIPS, ETC.

e. IF YOU HAVE EVER BEEN EXPELLED FROM SCHOOL, OR PLACED ON PROBATION, EITHER FOR

ACADEMIC OR DISCIPLINARY REASONS, EXPLAIN (Continue in Item 41(Remarks))

Basis for determination of qualifications and background information for eligibility for consideration for appointment as a Regular Army or Army Reserve

commissioned/warrant officer or for selection for attendance at the US Army Officer Candidate School.

To obtain an appointment as a commissioned or warrant officer in the Regular Army or Army Reserve, or to obtain selection to attend the US Army Officer Candidate

School.

12. MARITAL

STATUS

13. NUMBER OF DEPENDENTS UNDER 18

YEARS OF AGE

14. DATE OF

BIRTH

ENLISTED

WARRANT

OFFICER

WARRANT

OFFICER

COMMIS-

SIONED

IF YES, ATTACH REQUEST FOR WAIVER LISTING THE DATE, THE NATURE OF EACH ALLEGED OFFENSE OR VIOLATION, THE NAME AND LOCATION OF

33.

PROBATION, PAROLED OR PARDONED, OR HAVE YOU EVER BEEN ORDERED TO DEPOSIT BAIL OR COLLATERAL FOR THE VIOLATION OF ANY LAW, POLICE REGULATION OR

25.

32.

24. ARE YOU NOW, OR HAVE YOU EVER BEEN A CONSCIENTIOUS OBJECTOR?

31. HAVE YOU EVER APPLIED AND NOT BEEN SELECTED FOR: a. ROTC

e. IF ANSWER IS "YES", EXPLAIN FULLY

f. DATE CURRENT ACTIVE DUTY TOUR TERMINATES

YES NOYES NO

AS A WARRANT OFFICER

AS A COMMISSIONED OFFICER

d. APPOINTMENT IN REGULAR ARMY

AS A WARRANT OFFICER

AS A COMMISSIONED OFFICER

a. ORGANIZATION

(US Armed Forces, USCG, NOAA,

US Public Health Service, Peace Corps)

e. HIGHEST GRADE

AND COMPONENT

FROM TO

c. BRANCH/MOS

(As appropriate)

d. PRIOR

SERVICE NO.

(If applicable)

a. ORGANIZATION

(US Armed Forces, USCG, NOAA,

US Public Health Service, Peace Corps)

e. HIGHEST GRADE

AND COMPONENT

FROM TO

c. BRANCH/MOS

(As appropriate)

d. PRIOR

SERVICE NO.

(If applicable)

YES

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26.

g. DATE OF LAST ADL PROMOTION

NO YES

DIRECT APPOINTMENT OCS

ARNGUS:

USAR:

DIRECT APPOINTMENT

ROTC

OTHER

OCS

NO YES b. OCS NO YES

YES

HAVE YOU EVER UNDER EITHER MILITARY OR CIVILIAN LAW BEEN INDICTED OR SUMMONED IN TO COURT AS A DEFENDANT IN A CRIMINAL PROCEEDING (Including any

proceedings involving juvenile offenses, article 15, UCMJ, and any court-martial) REGARDLESS OF THE RESULT OF TRIAL, OR CONVICTED, FINED, IMPRISONED, PLACED ON

ORDINANCE? (Exclude traffic violations involving a fine or forfeiture of $100 or less).

30. AWARDS (Do not list theater or service medals)

HAVE YOU EVER RESIGNED OR BEEN ASKED TO RESIGN IN LIEU OF ELIMINATION PROCEEDINGS; BEEN DISCHARGED IN LIEU OF ELIMINATION, FURLOUGHED

(other than

regular furlough or leave),

OR PLACED ON INACTIVE STATUS WHILE SERVING IN THE US ARMED FORCES; OR, HAVE YOU EVER RESIGNED OR BEEN ASKED TO RESIGN FROM

A POSITION WHILE IN PRIVATE OR GOVERNMENT EMPLOYMENT?

(If yes, state circumstances; if more space is required, continue on separate sheet).

ARE YOU NOW OR HAVE YOU EVER BEEN IN THE MILITARY SERVICE OF OR BEEN EMPLOYED BY A FOREIGN GOVERNMENT (If yes, give dates, country and type of service or

employment)

29. SOURCE OF CURRENT COMMISSION (If applicable)

27. ACTIVE MILITARY SERVICE (Indicate tour with each organization separately - show ROTC Camps in Item 39)

28. RESERVE OR NATIONAL GUARD SERVICE (Not on active duty)

c. APPOINTMENT IN RESERVE COMPONENT (USAR/ARNG)

b. DATES (Day, Month, Year)

(If yes, attach affidavit)

ROTC (SMP)

THE COURT OR PLACE OF HEARING, AND THE PENALTY IMPOSED OR OTHER DISPOSITION OF EACH CASE AND FURNISH COPY OF COURT ACTION OR DETAILED STATEMENT IN

AFFIDAVIT FORM AS TO THE OUTCOME OF EACH CASE.

I UNDERSTAND THAT, IF I AM SELECTED FOR APPOINTMENT, I WILL BE EXPECTED TO ACCEPT SUCH ASSIGNMENTS AS ARE IN THE BEST INTEREST OF THE SERVICE

REGARDLESS OF MY MARITAL STATUS AND/OR RESPONSIBILITY FOR DEPENDENTS; AND IT IS MY RESPONSIBILITY TO MAKE APPROPRIATE ARRANGEMENTS FOR THE CARE

OF MY DEPENDENTS SHOULD I BE REQUIRED TO PERFORM DUTY IN AN AREA WHERE DEPENDENTS ARE NOT PERMITTED.

ROTC (ECP)

COMMIS-

SIONED

d. STATE AND CURRENT REGISTRATION NUMBER

TO FROM

41. REMARKS (Experience, proficiencies and special abilities not shown elsewhere in this application. Those required to enter primary entry specialties, see Para 1-27d,e, AR 601-100). (If more

space is required, attach additional sheet)

NAME AND LOCATION OF SCHOOL OR HOSPITAL

(2)

d. SPECIALTY BOARDS

f. PLACE IN WHICH CURRENTLY LICENSED

FROM

SUBJECT OR COURSE

SUCCESSFULLY COMPLETED AROTC PROGRAM AS FOLLOWS

c. CAMP TRAINING

a. NAME AND ADDRESS OF EMPLOYER

42. THE INFORMATION CONTAINED HEREIN IS TRUE

TO THE BEST OF MY KNOWLEDGE AND BELIEF.

RELIGIOUS DENOMINATION BY

WHICH YOU WILL BE ENDORSED

b. NAME AND LOCATION OF HOSPITAL

a. TRAINING

LEVEL TYPE

INTERNSHIP

RESIDENCY TNG

SPECIALTY TNG

FROM TO

STATE AND DATE OF INITIAL

REGISTRATION

(Day, Month, Year)

DATE SIGNATURE OF APPLICANT

c. MONTH AND YEAR

b. JOB TITLE

FROM TO

COURSE

a. BASIC

b. ADVANCED

a. NAME OF NURSING OR ACCREDITED PROFESSIONAL SCHOOL b. LOCATION

FROM TO

(1)

(3)

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YES

35.

APPLICANTS FOR

CHAPLAINS BRANCH ONLY

34.

APPLICANTS FOR JUDGE ADVOCATE GENERAL'S CORPS ONLY

BARS OF WHICH YOU ARE A MEMBER (Specify dates)

36.

APPLICANTS FOR MEDICAL AND DENTAL CORPS ONLY

37. APPLICANTS FOR ARMY NURSE CORPS AND ARMY MEDICAL SPECIALIST CORPS ONLY

c. DATES OF ATTENDANCE

(Mo, Yr)

f. POSTGRADUATE COURSES (Include courses at general hospitals, service schools, and short courses)

38. HAVE YOU BEEN EMPLOYED BY THE US ARMY AS A DIETITIAN, OCCUPATIONAL OR PHYSICAL THERAPIST? (If yes, give dates)

39.

ARMY ROTC (To be completed only by prospective ROTC graduates applying for appointment in USAR or RA)

(1) INSTALLATION (Basic)

(2) INSTALLATION (Advanced/Ranger)

40. MAIN CIVILIAN EMPLOYMENT

b. PRINCIPAL DUTIES (Describe briefly)

e. DATES OF CERTIFICATION

(Day, Month, Yr)

c. DATES

(Month and Year)

COMPLETION DATE (Month, Year)

DATES ATTENDED (Month and Year)

DATES OF ATTENDANCE (Month, Year)

SEMESTER

CREDITS

EARNED

MONTHS. HIS PRINCIPAL DUTY IS

SIGNATURE

OFFICER OF THE ARMY RECOMMEND HIS APPOINTMENT.

ENCLOSURES

ORGANIZATION

b. STATEMENT

TO:

ORGANIZATION

ENCLOSURES

DATE

a. STATEMENT

TO:

TYPED NAME, GRADE AND TITLE

BRANCH FOR ASSIGNMENT

DATE

THIS PAGE NOT TO BE COMPLETED BY APPLICANT

APPLICANT WILL HAVE SUCCESSFULLY COMPLETED AT THIS INSTITUTION THE PRESCRIBED COURSE FOR THE UNIT ON

b. APPLICANT

c. APPLICANT

d. I CONSIDER APPLICANT PHYSICALLY, MENTALLY, MORALLY, AND PROFESSIONALLY QUALIFIED FOR APPOINTMENT AS A

e. APPLICANT WILL ATTAIN FULL QUALIFICATION FOR, AND SHOULD BE APPOINTED ON

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HAS NOT COMPLETED SUCCESSFULLY THE REQUIRED CAMP TRAINING.

WILL HAVE ATTAINED

WILL NOT HAVE ATTAINED, A BACCALAUREATE DEGREE UPON SUCCESSFUL COMPLETION OF THE ROTC COURSE.

HAS

(Date)

(Day, Month and Year)

REGULAR

2. I DO DO NOT RECOMMEND THE APPLICANT.

SIGNATURE

1. I HAVE KNOWN THE APPLICANT FOR MONTHS. HE HAS SERVED UNDER ME FOR

1. I HAVE KNOWN THE APPLICANT FOR MONTHS. HE HAS SERVED UNDER ME FOR MONTHS. HIS PRINCIPAL DUTY IS

PART I - RECOMMENDATION FOR APPOINTMENT OF ROTC GRADUATE AS A (REGULAR) OR

(RESERVE) COMMISSIONED OFFICER OF THE ARMY (AR 601-100, AR 145-1) (To be completed by PMS only)

TO: (Appropriate Region Commander)

PART II - RECOMMENDATION FOR APPLICANTS FOR OCS ONLY (AR 351-5)

FROM: (Name and Address of Institution)

SIGNATURE AND GRADE (PMS)

3. REMARKS (Include your opinion as to his/her overall ability (to include leadership) and value to the service).

RESERVE COMMISSIONED