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U.S. ARMY ROTC GREEN TO GOLD
ACTIVE DUTY OPTION PROGRAM
www.goarmy.com/rotc/enlisted-soldiers.html
INFORMATION BOOKLET
As of 12 June 2020
THE ARMY RESERVE OFFICERS' TRAINING CORPS (ROTC) TWO-YEAR GREEN TO GOLD ACTIVE DUTY OPTION PROGRAM FOR
U.S. ACTIVE DUTY COMPONENT ENLISTED PERSONNEL
PAGE 3467911 12 17 18 24 28 32 45
CONTENTS General Information Eligibility Ineligibility Application Procedures Removal from the Program Green to Gold Counterpart Program Points of ContactApproved Academic DisciplinesRequired Documents CC FORM 174-R & Instructions (Application) CC FORM 104-R & Instructions (Planned Academic Program Worksheet) CC FORM 145-1-6 & Instructions (Standard Transfer Evaluation) DD FORM 2808 & DD FORM 2807-2 (DODMERB Medical Exam) Green to Gold Waiver Matrix Waiver Examples:
Age 46 Civil Conviction 52 Standardized Test Scores 56 CGPA 58 Reenrollment 60 Dependency 62 AFS 66
It is the applicant's responsibility to ensure that the online application is started, completed and all required documents are uploaded by the below suspense date.
Critical Dates: 12 JUN 20 : Application window opened. 27 NOV 20 : Last day to create online application/ Phase 1 document submission. 11 DEC 20 : Selection Board Convenes. 15 DEC 20 : Selection Board Recesses.
Announcement Date: Applicants selected to move to Phase 2 should be notified late JAN 20 via MILPER Message published by HRC.
Status Updates: If applicants have a change of address, want to withdraw from competition, or have a change in command after submission of application, they must notify this command as soon as possible, in writing via email to [email protected].
Applicants who are not selected must re-apply; applications will not be carried over into the next cycle.
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GENERAL INFORMATION
Mission Statement
The Green to Gold (G2G) Active Duty Option (ADO) Program is a two‐year program that provides
eligible, Regular Army (RA) Enlisted Soldiers an opportunity to complete their first Baccalaureate degree
or their first Master’s degree. Upon the successful completion of their degree program the Soldier is
commissioned as an Officer in the RA.
Note: Applicants enter the program as academic Juniors or Graduate students. Furthermore, they retain
all benefits, base pay, allowances, and promotional status until commissioning.
Phases
The Program consist of two phases:
Phase One: the preliminary process. This phase consists of creating an online application, submission of
board required documents, verifying board eligibility, and packet appearance before a selection board.
Phase Two: The qualification process. Selected Soldiers must be administratively and medically qualified
prior to awarding of a Winner Letter. To become administratively qualified the applicant must ensure all
required documents (to include waivers) are uploaded to the application portal. To be medically
qualified the applicant must be cleared by the Department of Defense Medical Evaluations Review
Board (DoDMERB), there are no exceptions.
Selection Process
The selection process consists of eight Professors of Military Science (PMS) reviewing all completed
applications. Selections are based on the Scholar, Athlete, Leader (SAL) concept. Once the selection
process is completed an Order of Merit List is established.
HRC will publish an MILPER Message listing those Soldiers selected to advance to Phase Two.
Winner Letter
The Winner Letter is produced upon completion of phase two. The applicant’s file receives final
verification to ensure all requirements have been completed. The Winner Letter will be sent to the
applicant’s Company level Commander through email. Upon receipt of the Winner Letter the applicant
must accept or decline the offer and return the signed Letter of Intent (LOI). USACC will contact HRC and
assignment instructions will follow.
Obligation
Applicants meeting all requirements and entering into the program will incur an 8 year service obligation
upon commissioning. This will be fulfilled by serving in RA for a minimum of 3 years followed by 5 years
of service in the Army in either an Active Duty or Reserve status.
Waiver Process
All required waivers will be submitted on a fillable DA Form 4187 and routed through the applicants’
ROTC Chain of Command. Examples are located in this handbook starting on page 39
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Tuition
Applicants are responsible for their educational expenses; e.g., tuition, books, and fees. They may
receive any portion of the GI Bill benefits they have earned since entering into the military. However,
IAW Department of Defense Directive 1322.8, Soldiers selected to participate in this program are not
eligible to use tuition assistance.
NOTE: GI Bill payments for Soldiers on active duty may have limitations; therefore it is important to
contact the Department of Veterans Affairs for specific entitlements. For information regarding
eligibility for GI Bill contact your installation’s Education Center or visit the Department of Veterans
Affairs website at http:// www.va.gov or call 1‐888‐442‐4551. It is the applicants’ responsibility to
ensure he/she fully understands all benefits before making any decision.
Class Attendance
75% of scheduled classes must be taken in a classroom environment. Applicant must be enrolled as a
full‐time student, taking a minimum of 12 (9 for Master’s) and maximum of 18 credit
/semester hours.
NOTE: Exceptions of the 75% rule will be considered based on course curriculum.
Counterpart
For questions or assistance in completing the application contact the ROTC Program located nearest
your Military installation. These “Counterpart Programs” are listed on page 13 of this handbook.
Soldiers stationed outside the United States are also assigned a Counterpart Program staffed specifically
to assist them.
Assignments
During any phase of the Green to Gold application, if a Soldier comes down on assignment it is the
Soldier's responsibility to contact their Branch Manager for deferment/deletion of the assignment
Website:
https://www.hrc.army.mil/content/Enlisted%20Personnel%20Management%20Directorate%20(EPMD) .
Once selected for Phase 2, Soldier Assignment Eligibility and Availability (AEA) Code will be updated
from a "L, no current reassignment restrictions" to "I, Officer Producing Candidate School Pending."
Soldiers may still attend NCOES course while coded "I" prior to college start to become fully eligible for
promotion while at the academic studies. AEA Code "N, deployment Stabilization" will not be changed
by HRC, contact Chain and Command and S1 for updating.
ELIGIBILITY
To be eligible to participate in this program, a Soldier must—
1. Be a citizen of the United States. No waiver authorized.
2. Be eligible for appointment as a commissioned officer in the U.S. Army under the provisions of AR
135‐100.
3. Be under 30 years of age upon graduation and completion of all requirements for commission. Waiver
authorized.
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4. Have completed less than 10 years Active Federal Service (AFS) at the projected time of graduation
and commissioning. Waiver authorized.
5. Have favorable recommendations from Soldiers current Chain of Command (immediate and Battalion
Level Commander).
6. Not be currently scheduled to attend an approved reclassification MOS training school will not be
considered for a waiver until a request for cancellation of the approved reclassification MOS training has
been processed and approved by the proper approval authority.
7. Have at least 48 months remaining upon entering the program. Soldiers who do not meet the service
remaining requirement for this program must be processed IAW AR 601‐280, paragraph 4‐6, before
orders can be issued directing movement to the Student Detachment, Fort Jackson, South Carolina. No
waiver authorized.
8. Have received a score of 110 or higher on the General Technical (GT) Aptitude Area of the Army
Classification Battery. If the score is below 110, a Soldier may re‐test through their installation education
centers. Soldier must meet minimum requirements by the application due date. No waiver authorized.
9. Have a minimum cumulative grade point average of 2.5 on a 4.0 grading point system (unweighted) on
all previous college work completed. Waiver authorized for 2.0‐2.49.
10. Have passed an Army Physical Fitness Test (APFT) and achieved at least a score of 180 or higher
with a minimum of 60 points in each event (alternate events are not authorized) within the last six
months of receipt of the application. APFT information must be updated on the Enlisted Record Brief
under the Personal/Family Data section. No waiver authorized. NOTE: Although some Units may
transition to the Army Combat Fitness Test (ACFT) during the application cycle; all applicants must
submit an APFT to be used as a common measuring stick by the Selection Board.
11. Have two years remaining (4 semesters/6 quarters) as a full time student as indicated on CC Form
104‐R, Planned Academic Program Worksheet. Summer sessions (between Junior and Senior year) are
authorized but cannot interfere with Advance Camp attendance.
NOTE: Transfer hours accepted by the school of attendance must be included on USACC Form 104‐R,
block 5c as credits applied towards the degree being pursued. This information must be confirmed by
the school’s administration through an official evaluation of all official transcripts. Course overload
(more than 6 classes per semester/quarter) is NOT permitted. Students must be enrolled full‐time with
75% of the curriculum in traditional class‐room settings. Exceptions to the 75% rule will be considered
based on course curriculum (NOT University selected).
12. Obtain a letter of acceptance from the Professor of Military Science (PMS) into the Army ROTC
Program affiliated with the college/university the Soldier plans to attend and the start date of the school
term. Contact the PMS at the institution in order to receive this letter.
13. Have a secret or higher security clearance. Soldiers without a clearance must provide a memo from
their unit’s security manager’s office that states that the individual has a favorable closed Tier‐3 (T3),
Teir‐5 (T5), Single Scope Background Investigation (SSBI), or National Agency Check Local and Credit
(NACLC) investigation.
14. Be medically qualified IAW AR 40‐501, Standards of Medical Fitness dated 12 April 2004, Chapter 2,
to participate in the ROTC program as determined by Department of Defense Medical Examination
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Review Board (DoDMERB), the agency responsible for reviewing medical examinations (must be
medically qualified by 15 July or request to be deferred until the following Fall Semester).
15. Have no more than three dependents (including spouse). Waiver authorized.
INELIGIBILITY
Soldiers are ineligible for the program if he/she‐
1. Requires anything other than 4 semesters/6 quarters as a full‐time student to earn the degree. Course
overload or less than full‐time status is not authorized.
2. Does not have a favorable recommendation by their chain of command.
3. Is ineligible for reenlistment.
4. Is a conscientious objector, as defined in AR 600‐43, Conscientious Objection.
5. Has a misdemeanor record of a Domestic Violence Conviction.
6. Is under suspension of favorable personnel action (FLAGS) IAW AR 600‐8‐2.
7. Will have 10 years or more of AFS at time of commissioning. Waivers authorized.
8. Is under probation for a civil conviction or charges are pending at the time of application.
9. Had had any adverse juvenile adjudication (even if the record may have been sealed or expunged), or
have been arrested, indicted, or convicted by a civil court or military law for other than minor traffic
violations (fine of $250 or less), or had imposed other adverse disposition; e.g. attend classes, perform
community service or perform any other similar acts) unless waived for this program. Waivers are
authorized.
10. Is a Soldier without a spouse and have one or more dependents under 18 years of age is disqualified
except as provided in paragraph 11(c) below. Waiver authorized.
11. Dependents:
a. A Soldier with a spouse in a military component of any armed service (excluding members of the
Individual Ready Reserve (IRR)) that has one or more household members under 18 years of age. Waiver
authorized.
b. A divorced Soldier may be processed for enrollment without a waiver when the child or children
has/have been placed in the custody of the other parent, an adult relative or legal guardian by court
order and the Soldier is not required to provide child support. Copies of court documents must be
provided with the application.
c. A divorced Soldier may be processed for a dependency waiver when the Soldier has joint/sole custody
and/or the Soldier is required to provide child support. In both cases mentioned, the Soldier must sign a
statement of understanding acknowledging he or she can be removed from the program should they
regain custody of the child or children while enrolled in ROTC. An exception to the removal will only be
considered if extraordinary circumstances prevail such as the death of the legal guardian or adult.
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APPLICATION PROCEDURES
Read instructions carefully. Application must be completed online. Go to:
www.goarmy.com/rotc/enlisted‐soldiers.html, scroll down to Green to Gold Active Duty Option, then
click on “Learn More”, next scroll to the bottom of the page and click on “Take the Next Step: Create An
Account”. Once account is created, you now have access to the Green to Gold Access Portal. To log into
the Access Portal, go to: https://gtg.usarmyrotc.com/dana‐na/auth/url_3/welcome.cgi, enter the email
address you used to create the account as your username, enter password, then proceed with the
application.
A completed application will consist of the items listed below: (A checklist is on page 17 of this
handbook). It is the Soldier's responsibility to ensure all required documents are uploaded through the
Green to Gold Access Portal, NO LATER THAN the last Saturday of November. Incomplete files will not
be forwarded to the Army ROTC Selection Board for review. NOTE: RETAIN A COPY OF ALL DOCUMENTS
FORWARED FOR RECORD.
Phase 1 Requirements:
1. USACC FORM 174‐R (Green to Gold Program Application): This form is automatically generated in the
online application.
a. If Item 13, civil conviction is yes A WAIVER REQUEST FOR THE DISQUALIFICATION MUST BE
SUBMITTED as soon as possible. The waiver request along with any supporting documents must be
submitted along with the proper endorsement or approval with the application. Include a complete
written affidavit with the description of the offense, to include all circumstances leading up to arrest and
conviction and complete sentence imposed. In addition, submit a copy of the court record which
indicated the charge, plea, and/or findings, as well as the sentence imposed and the record showing
satisfaction of the sentence (when court records are not available, this fact must be established by
correspondence from the court). The statement must be certified under oath. If an offense occurs after
submission of the application, inform this headquarters and request a waiver.
b. A favorable recommendation from the immediate commander and field grade commander
commenting on the Soldier’s officer‐like qualities, i.e., Scholar‐Athlete‐Leader (S‐ A‐L) criteria, leadership
potential, appearance, personality, military record and aptitude for further military training.
2. ERB: An updated copy of the ERB indicating citizenship. Must include most recent APFT data (within 6
months of applying). NOTE: This ERB is “you” appearing before the Selection Board. Ensure it is current
and complete.
3. TRANSCRIPTS: Official transcripts of all colleges attended. The school accepting applicants for
attendance should establish a cumulative grade point average (CGPA). CGPA should be annotated on
USACC Form 145‐1‐6. However, if a CGPA is not established by the college/ university, Cadet Command
will compute the grades from all previous college work completed and establish a CGPA. If applicants
received college credit by means of the USAFI or CLEP tests, official results of such tests must also be
furnished to this headquarters. College Grade Reports are not transcripts and are unacceptable.
Transcripts which appear in languages other than English must be translated prior to submission.
Soldiers are responsible for ensuring all official transcripts are enclosed in their packets.
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4. USACC FORM 145‐1‐6 (Evaluation of Transfer of Credit): Page 1 of the form is required for Phase 1.
This is a the Soldier’s good faith estimate of how many credits and from what institution(s) he/she will
be transferring to their requested university. This form is not required for those Soldiers applying for the
Master’s program.
5. USACC FORM 104‐R (Planned Academic Program Worksheet): The Phase 1 USACC Form 104‐R is the
Soldier’s good faith estimate of how many credits/classes will be required the earn his/her degree upon
entry into the program. No signature other than the Soldier’s is required.
6. DA Photo: Photo must be taken in Army Service Uniform. Soldiers who are deployed and unable to
obtain an official photo may take a photo in duty uniform (without headgear or weapon), against a solid
background. Photo should be from waist up.
Phase 2 Requirements
1. USACC FORM 145‐1‐6: All three pages of this form are required for Phase 2. Evaluation should include
course number and title, course grade, credit hours attempted and earned toward the degree pursuing
and grade point average if available. (NOTE: Some university systems may accept transfer credit for
placement purposes and still require additional evaluation by the department awarding the degree. This
may change the applicant’s academic status).
2. USACC FORM 104‐R: For Phase 2 this form must be completed by the university’s ROTC Program,
verified and signed by both the Soldier, the school registrar’s office, and the PMS. The PMS or his/her
representative will assist applicants in the completion of this form. Soldiers selected to participate in the
program must attend the institution that provides the USACC Form 104‐R.
3. LOA (Letter of Acceptance from the PMS): The letter should verify acceptance to the university,
acceptance into the ROTC program, and academic status. The letter must also indicate school start date.
4.WAIVERS: Copy of waivers and/or waiver requests, as applicable. All waivers must be submitted on a
fillable DA 4187 (see pages 39‐59 for examples) and must be digitally signed. NOTE: Although waivers
are not required until Phase 2 it is recommended to submit Civil Conviction Waivers ASAP.
5. DODMERB MEDICAL EXAM: DD Forms 2808 and 2807‐2. No other forms are authorized. These forms
can be found at the following site: https://www.esd.whs.mil/Directives/forms/dd2500_2999/ (select
the two forms from the list): unfortunately, these forms do not include all information required for
screen of a Green2Gold applicant:
a) DODMERB has provided USACC with overprinted FORMs that include all required data for screening
of a Green2Gold applicant. These modified documents are available on the Green2Gold online
application website. Unfortunately, some Military Treatment Facilities (MTF) will not use the modified
forms.
b) In some cases a Green2Gold applicant is at a remote location not near a MFT or some MFTs with not
use DD FORMS 2808 and 2807‐2. If that is the case, RMID can schedule the Green2Gold applicant for a
DODMERB Exam at a civilian provider through (DODMETS).
So in short Green2Gold applicants have 3 options and are listed below by preference:
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1. Have the MFT complete the DD Forms 2808 and 2807‐2 provided on the Green2Gold
online application website.
2. Have the MFT use forms they download from:
https://www.esd.whs.mil/Directives/forms/dd2500_2999/. (Understand with this
option you WILL be required to submit Remedials to DODMERB)
3. Send an email to: [email protected] stating that you are a
Green2Gold applicant and require a DODMERB Exam through a civilian provider.
**ALTHOUGH DODMERB QUALIFICATION IS NOT REQUIRED UNTIL PHASE 2; IT IS HIGHLY
RECOMMENDED THAT SOLDIERS START THE DODMERB QUALIFICATION PROCESS AS EARLY AS
POSSIBLE; AS THE QUALIFICATION PROCESS MAY TAKE SOME TIME**
c) Write your AKO email address at the top of the DD Form 2808. DODMERB will not process without
AKO email.
d) Medical examinations must be submitted with the application. This headquarters will forward the
exam to DODMERB for processing. DO NOT SEND THE EXAM DIRECTLY TO DODMERB. Delay in
forwarding the exam could result in not being medically qualified in sufficient time to enroll in the
program.
Any remedial or follow‐up required by DODMERB must be completed prior to any offer being extended.
Applicants can monitor their medical status by logging into the DODMERB website at:
https://dodmerb.tricare.osd.mil, once there, click on “Applicants: click here to create an account”
DEFERMENT: If an applicant selected for Phase 2 is not fully qualified (Medically/Administratively) by
01 JUL of the cycle year that Soldier must defer until following Fall Semester (Deferment to Spring
Semesters are not allowed).
RELEASE FROM THE PROGRAM
1. Soldiers selected to participate in the program must maintain eligibility. Failure to maintain eligibility
requirements will result in release from the program and immediate re‐assignment. A Soldier may be
released from the program for:
a) Failure to pass a record APFT (will be administered every six months).
b) Failure to maintain a CGPA of 2.0 or higher.
c) Failure to complete commissioning requirements in the time allotted (21 consecutive months).
d) Failure to maintain height/weight standards IAW AR 600‐9.
e) Misconduct as defined by AR 145‐1, para 3‐43(12).
f) Lack of aptitude as defined by AR 145‐1, para 3‐43(13).
g) Undesirable character as defined by AR 145‐1, para 3‐43(14).
h) Indifferent attitude as defined by AR 145‐1, para 3‐43(15).
i) Change in medical condition which makes the Soldier ineligible for commissioning.
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2. If a Soldier is released from the program at any time after enrollment, the established Service
Remaining Requirement (SSR) will remain in effect and the Soldier will be reassigned immediately based
upon the needs of the Army.
10
COUNTERPARTS Post ROTC Battalion Telephone
Aberdeen Proving Morgan State Univ (443) 885‐3264
Alaska (All Installations) Univ Of Alaska (907) 474‐7501
APO AP 8th Bde (253) 477‐3581
APO‐AA Campbell University (910) 893‐1590
APO‐AE Campbell University (910) 893‐1590
Ft Belvoir, VA George Mason University (703) 993‐2707
Ft Benning, GA Columbus State (706) 568‐2058
Ft Bliss, TX Univ of Texas at El Paso (915) 747‐6692
Ft Bragg, NC Campbell University (910) 893‐1590
Ft Buchanan, PR U/Puerto Rico‐Rio Piedras (787) 764‐0000x7653
Ft Campbell, KY Austin Peay State Univ (931) 221‐6149
Ft Carson, CO U Of Co At Colorado Springs (719) 255‐3520
Joint Base M‐D‐L Rutgers Univ (732) 932‐7313x11
Ft Drum, NY Syracuse Univ (315) 443‐8233
Joint Base Langley‐Eustis College Of William and Mary (757) 221‐3600
Ft Gordon, GA Georgia Regents Univ (912) 706‐4647
Ft Hood, TX Tarleton State University (254) 616‐3493
Ft Huachuca, AZ University Of Arizona (520) 621‐1078
Fort Irwin, CA Claremont McKenna College (909) 621‐8102
Ft Jackson, SC Univ Of South Carolina (803) 777‐3639
Ft Knox, KY University of Louisville (502) 852‐7902
Ft Leavenworth, KS University Of Kansas (785) 864‐1109
Ft Lee, VA Virginia State Univ 3rd Bde (804) 524‐5537
Ft Leonardwood, MO 3rd Bde (847)688‐3328x112
Joint Base Lewis‐McChord 8th Bde (253) 477‐3581
Ft Rucker, AL Auburn University (334) 844‐5641
Ft McPherson, GA Georgia Inst Of Tech (404) 894‐9938
Ft Meade, MD Bowie State (301) 860‐3563
Joint Base Myer‐HH Georgetown Univ (202) 687‐7008
Ft Polk, LA NW Louisiana State (318) 357‐5177
Ft Riley, KS Kansas State Univ (785) 532‐6754
Ft Detrick, MD McDaniel College (410) 857‐2723
Ft Sam Houston, TX Univ Of TX At San Antonio (210) 458‐4622
Ft Sill, OK Cameron University (580) 581‐2344
Ft Stewart, GA Georgia Southern Univ (912) 478‐0040
Hawaii (All Installations) University Of Hawaii (808) 956‐7766
Redstone Arsenal, AL Alabama A&M (256) 372‐5775
White Sands MR, NM New Mexico State Univ (575) 646‐4030
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Academic Discipline- Mix 1 Generalist ATH THAI ATU TURKISH
CODE ACADEMIC TITLE
AAA ART COMMERCIAL AAE ARABIC-EGYPTIAN AAK ARABIC-JORDANIAN AAL ARABIC-LIBYAN AAN ARABIC-SAUDI AAP ARABIC-SYRIAN AAQ ARABIC-LEBANESE AAX ART GENERAL AAZ ARABIC ABN BENGALI ABX LANGUAGE/LITERATURE
CLASSICAL ACA RELIGIOUS EDUCATION ACB PASTORAL COUNSELING ACC RELIGION/THEOLOGY ACD CHINESE CANTONESE ACM CHINESE MANDARIN ADG ARABIC-IRAQI ADU DUTCH ADX ENGLISH AEX MUSIC AFA PUBLIC SPEAKING AFB DRAMATICS AFC HOMILETICS AND
COMMUNICATION SKILLS AFR FRENCH AGA BROADCASTING
(ANNOUNCER) AGB PRODUCTION MOTION
PICTURE AGC PRODUCTION AHJ HINDI AHX LANGUAGE/LITERATURE
FOREIGN AJA JAPANESE AJN INDONESIAN AJT ITALIAN AKP KOREAN AKX JOURNALISM-
WRITING/EDITING ALA SPANISH (LATIN
AMERICAN) ALX PHILOSOPHY AML MALAYSIAN ANR NORWEGIAN ANX ARTS LIBERAL APQ PORTUGESE (BRAZILIAN) APY PORTUGESE (EUROPEAN) AQE ARABIC-EASTERN AQW ARABIC-WESTERN ARU RUSSIAN ASC SERBO-CROATIAN ASR SPANISH (CASTILLIAN) ASY SWEDISH ATA TAGALAC
AUR URDU AXX ARTS-CLASSIC/GENERAL BAF COMMERCIAL-
MARKETING/MERCHANDISING BAK LABOR RELATIONS BAO ORGANIZATION
BEHAVIOR- ORGANIZATION EFFECTIVENESS
BAP ORGANIZATION BEHAVIOR-PERSONNEL MANAGEMENT
BAR COLLEGE ADMINISTRATION
BAS FOOD DISTRIBUTION BAV HUMAN RESOURCES BBA ADMINISTRATION PUBLIC BBB PERSONNEL
MANAGEMENT/ ADMINISTRATION
BBH MANAGEMENT INSTITUTIONAL
BBM CHURCH MANAGEMENT BBN HOTEL-RESTAURANT
MANAGEMENT BBS SAFETY BCA FOREIGN TRADE BMS MASTERS-ADVANCED
MILITARY STUDIES CUF COGNITIVE SCIENCE DAA AGRICULTURE GENERAL DAH HORTICULTURE DAK HUSBANDRY ANIMAL DAL HUSBANDRY POULTRY DKF MILITARY SCIENCE
(OTHER THAN U S ACADEMIES
EAB CULTURAL FOUNDATIONS EAC ETHNOLOGY EAD INTERDISCIPLINARY
STUDIES EAX ANTHROPOLOGY EBX AREA STUDIES ECA POLICE SCIENCE AND
ADMINISTRATION ECB CORRECTIONS ECF FORENSIC SCIENCE ECJ CRIMINAL JUSTICE ECX CRIMINOLOGY EED VOCATIONAL AND
EDUCATIONAL GUIDANCE
EEE VOCATIONS SUBJECTS (CRAFTS, TRADE)
EEF GENERAL EDUCATION TECHNOLOGY
12
EEG SPECIAL EDUCATION BAX BUSINESS EEX EDUCATION GENERAL ADMINISTRATION
(TEACHING) BAY AVIATION BUSINESS EFA RECREATIONS ADMINISTRATION EFB RECREATION AND PARK BBD COMMERCIAL AVIATION
ADMINISTRATION TRANSPORTATION EFC EDUCATION PHYSICAL BBE RESEARCH PROGRAM EGX HISTORY GENERAL MANAGEMENT EHX ECONOMICS HOME BBF MANAGEMENT LOGISTICS EKB INTERNATIONAL BBG TRANSPORTATION AND
RELATIONS TRAFFIC MANAGEMENT EKC FOREIGN AFFAIRS BBK MANAGEMENT ELX ARTS INDUSTRIAL INDUSTRIAL EMX LIBRARY BBL MANAGEMENT
SCIENCE/ARCHIVES AEROSPACE ENB PUBLIC SAFETY BBP PROCUREMENT AND ENC GOVERNMENT CIVIL CONTRACT END GOVERNMENT MILITARY MANAGEMENT ENE SOCIAL WORK BBR SYSTEMS MANAGEMENT ENF ADMINISTRATION SOCIAL BBT TELECOMMUNICATIONS
WORK MANAGEMENT ENX PUBLIC RELATIONS BBX MANAGEMENT GENERAL ENY PUBLIC AFFAIRS BCB STRATEGIC EPA PSYCHOLOGY INTELLIGENCE
ABNORMAL MANAGEMENT EPB PSYCHOLOGY BCC ADMINISTRATION,
EXPERIMENTAL MASTER OF SCIENCE EPD PSYCHOLOGY SOCIAL DEGREE EPE PSYCHOLOGY APPLIED BCD COMMERCE EPH PSYCHOLOGY CHILD BCE AVIATION MAINTENANCE EPK PSYCHOLOGY BCF INFORMATION SYSTEM
EDUCATIONAL MANAGEMENT EPL PSYCHOLOGY BCX BUSINESS ECONOMICS
COUNSELING BHA HEALTH SERVICES EPM PSYCHOLOGY ADMINISTRATION
INDUSTRIAL BWX DESIGN TECHNOLOGY EPX PSYCHOLOGY GENERAL BXX BUSINESS GENERAL ERA GEOPOLITICS CCL CITY PLANNING ERX POLITICAL SCIENCE CCM REGIONAL PLANNING ESX SOCIOLOGY CFW GEOGRAPHY (PHYSICAL) ETX MORTUARY SCIENCE CHE COMMUNICATIONS EXX SOCIAL SCIENCE DAB AGRONOMY SOIL
GENERAL SCIENCE YYY UNDECLARED DAD DAIRY SCIENCE
DAE FISH RESOURCES
Academic Discipline Mix 2 - Technical
CODE ACADEMIC TITLE
BAA ACCOUNTING/AUDITING BAC ADVERTISING BAD BANKING AND
FINANCING BAE FINANCE GENERAL BAM COMPTROLLERSHIP BAN COMPUTER SCIENCE
MANAGEMENT
DAF FOOD TECHNOLOGY DAM PLANT PATHOLOGY DAN SUGAR TECHNOLOGY DAP WILD LIFE RESOURCES DAS AVIATION SAFETY DAT TECHNICAL
MANAGEMENT DAX AGRICULTURE-FORESTRY
GRENERAL DBB NAVIGATION CELESTIAL DEA NAVIGATIONAL
TERRESTRIAL DED TOPOGRAPHY INCLUDING
PHOTOGRAMMETRY EAA ARCHEOLOGY
13
Academic Discipline Mix 3 - Physical Science/Analytical
CODE ACADEMIC TITLE
BAL OPERATIONS RESEARCH ANALYST (BUSINESS)
CFB PHYSICS, SPACE CFD SPACE SYSTEMS
OPERATIONS CUE COMPUTER SCIENCE CUP COMPUTER BASED
INSTRUCTION DAG HISTOLOGY DAI EMBRYOLOGY
DGD GEOLOGY TERRESTRIAL MAG-ELECTRICITY
DGE GEOLOGY ECONOMIC DGF GEOLOGY GENERAL DGG PALEONTOLOGY DGH MINERALOGY
PETROLOGY DGL METEOROLOGY
CLIMATOLOGY DGN NAUTICAL SCIENCES DGP OCEANOGRAPHY
HYDROLOGY DGX GEOPHYSICS DHA STATISTICS DHB MATHEMATICS
CRYPTANALYSIS
EDX ECONOMICS GENERAL DAR BIOMETRY EEB INSTRUCTIONAL DBA ASTRODYNAMICS
TECHNOLOGY DBC ASTROPHYSICS EEC EDUCATION INDUSTRIAL DBX ASTRONOMY EKD COMMUNICATIONS SCIENCES DCA BOTANY GENERAL EPC PSYCHOLOGY CLINICAL DCB ENTOMOLOGY EPF PSYCHOMETRICS/ DCC BACTERIOLOGY
PSYCHOPHYSICS DCD PARASITOLOGY EPG PSYCHOLOGY (ARTIFICIAL DCE TAXONOMY
INTELLIGENCE) DCF ZOOLOGY FAA CLINICAL OPTOMETRY DCG MED MICROBIOLOGY
MANAGEMENT DCK RADIATION BIOLOGY FAB LABORATORY SCIENCE DCL RADIOLOGICAL HYGIENE FAC NUCLEAR PHARMACY DCX BIOLOGY FBA DIETETICS DDA BIOCHEMISTRY GENERAL FBB DIETITIAN DDB CHEMISTRY ANALYTICAL
ADMINISTRATIVE GENERAL FBC DIETITIAN THERAPEUTIC DDC CHEMISTRY INORGANIC FBD DIETITIAN CLINICAL GENERAL FBX NUTRITION DDD CHEMISTRY ORGANIC FCA OCCUPATIONAL GENERAL
THERAPY DDE CHEMISTRY PHYSICAL FCB OCCUPATIONAL GENERAL
THERAPY – KINESIOLOGY DDF CHEMISTRY NUCLEAR FCX OCCUPATIONAL DDG CHEMISTRY
THERAPY (ARTS/CRAFTS) CERAMICS/GLASS FDA ANATOMY DDH GLASS TECHNOLOGY FDB PHYSICAL THERAPY DDK CHEMISTRY FDC PHYSICAL THERAPY ELECTROCHEMISTRY
ELECTOPHYSICS DDL CHEMISTRY TEXTILE FDD PHYSICAL THERAPY DDM CHEMISTRY PAPER
NEUROLOGY DDN CHEMISTRY INDUSTRIAL FDX PHYSICAL THERAPY DDO RADIOCHEMISTRY
CORRECTIVE EXERCISE DDP METALLURGY FEA PATHOLOGY SPEECH DDX CHEMISTRY GENERAL FEX AUDIOLOGY DEX GEODETIC SCIENCE FJA ENVIRONMENTAL DFX GEOGRAPHY
HEALTH GENERAL/ECONOMIC/ FKA SANITARY SCIENCE POLITICAL FLA PUBLIC HEALTH DGA GEOLOGY SURFICIAL PEX PRE-LAW DGB GEOLOGY PXX LAW GENERAL STRATIGRAPHY
DGC SEISMOLOGY
14
DHC MATHEMATICS CBX AGRICULTURE BALLISTICS ENGINEERING
DHX MATHEMATICS GENERAL CCD URBAN PLANNING DLA PHYSICS BIOPHYSICS CCF ENGINEERING
AND RADIOLOGY STRUCTURAL DLB PHYSICS ELECTRICITY/ CCG CIVIL ENGINEERING
MAGNETISM/ (STRUCTURAL ELECTRONIC DYNAMICS)
DLC HEALTH PHYSICS CCH ENGINEERING DLD PHYSICS NUCLEAR (TRANSPORTATION) DLE PHYSICS OPTICS LIGHT CCK RADIOLOGICAL SAFETY
(OPTICS) AND DEFENSE DLF PHYSICS THERMAL CCN ENGINEERING SPACE DLG JET PROPULSION FACILITIES DLH TECHNOLOGY NUCLEAR CCO ENVIRONMENTAL
REACTOR ENGINEERING DLK APPLIED SCIENCE CCP ENVIRONMENTAL DLL MEDICAL TECHNOLOGY HEALTH ENGINEERING DLM RADIOLOGICAL PHYSICS CCQ ENVIRONMENTAL SCIENCE DLN ACOUSTICS CCR CIVIL ENGINEERING DLP AERODYNAMICS (SANITARY) DLX PHYSICS GENERAL CCX CIVIL ENGINEERING DLY LASER/MICROWAVE CDA BIOMEDICAL
PHYSICS ENGINEERING DLZ PHYSICS CDX ENGINEERING CERAMIC
ASTRODYNAMICS CEX ENGINEERING CHEMICAL DMS MATERIAL SCIENCE CEY COMPOSITE MATERIALS DPS POLYMER SCIENCE CFA AEROSPACE DXX PHYSICAL SCIENCES ENGINEERING (SPACE
GENERAL TRAVEL) FGC VIROLOGY CFC SPACE SYSTEMS FHA SEROLOGY ENGINEERING FHX IMMUNOLOGY CFX ENGINEERING FIA TOXICOLOGY AERONAUTICAL FIB PHARMACOLOGY CFY CARTOGRAPHY FIC CHIROPRACTICS CFZ ASTRONAUTICAL FKX PHYSIOLOGY ENGINEERING GOB PHYSICIAN’S ASSISTANT CGA PRODUCTION DESIGN
TRAINING ENGINEERING GPA BASIC SCIENCE CGK GEOLOGICAL GPB PRE-DENTAL AND ENGINEERING
PRE-VET CGX ENGINEERING GPX PRE-MED ADMINISTRATION KXX PHARMACY CHA ENGINEERING LAX PHYSIOLOGIC OPTICS ELECTRONICS
CHB ENGINEERING RADIO
Academic Discipline Mix 4 - Engineering
CODE ACADEMIC TITLE
CAA ARCHITECTURAL ENGINEERING
CAB NAVAL ARCHITECTURE ENGINEERING
CAC ARCHITECTURE LANDSCAPE
CAX ARCHITECTURE GENERAL
CHF ELECTRONIC WARFARE SYSTEMS TECHNOLOGY
CHJ JOINT COMMAND, CONTROL & COMMUNICATION
CHX ENGINEERING ELECTRICAL
CKB ENGINEERING ORDNANCE CKC ENGINEERING RAILWAY CKD ENGINEERING
REFRIGERATION CKE ENGINEERING AIR
CONDITIONING
15
CUC OPERATIONS RESEARCH CKF ENGINEERING ANALYST
CKH HYDRAULIC ENGINEERING CUD
(ENGINEERING) COMPUTER ENGINEERING
MECHANICS (ARTIFICIAL CKK ENGINEERING HEATING INTELLIGENCE) CKL ENGINEERING CUG SOFTWARE ENGINEERING
AUTOMOTIVE CUX SYSTEMS ENGINEERING CKM ENGINEERING DIESEL CWX ENGINEERING TEXTILE CKN ENGINEERING EXPLOSIVE CXX ENGINEERING GENERAL CKO MISSILES AND CYA HUMAN FACTORS
MUNITIONS ENGINEERING CKP GUIDED MISSILES CYX ENGINEERING CKQ SANITARY ENGINEERING INDUSTRIAL CKX MECHANICAL
ENGINEERING CYY ROBOTICS ENGINEERING
CLA ENGINEERING NUCLEAR EFFECTS
CLB ENGINEERING REACTOR CLD CIVIL ENGINEERING
(CONSTRUCTION) CLE MAINTAINABILITY
ENGINEERING CLF NUCLEAR ENGINEERING CME MATERIAL ENGINEERING CMX ENGINEERING MARINE CNX ENGINEERING
METALLURGICAL CPE POLYMER ENGINEERING CPF POWER ENGINEERING CPG PLASTICS ENGINEERING CPX ENGINEERING MINING CQX ENGINEERING PIPELINE CRA FUEL TECHNOLOGY CRM ENERGY RESOURCE
MANAGEMENT CRX ENGINEERING
PETROLEUM CSX ENGINEERING PHYSICS CSY VERTICAL LIFT
TECHNOLOGY CTX ENGINEERING SAFETY CUA COMPUTER SCIENCE
(ENGINEERING) CUB OPERATIONS RESEARCH
(STRATEGIC & TACTICAL SCIENCE)
Academic Discipline Mix 5 - Nursing
CODE ACADEMIC TITLE
JXX NURSING GENERAL
16
DOCUMENTS
PROGRAM ADO DEGREE TYPE BACH GRAD CCF 174‐R B B DA PHOTO B B ERB B B CCF 104‐R (WORKING) B B CCF 145‐1‐6(Page 1) B X COLLEGE TRANSCRIPTS B B PMS LETTER S S CCF 104‐R (FINAL) S S CCF 145‐1‐6 (Pages 1‐3) S X DODMERB EXAM S S
B DOCUMENT REQUIRED TO BE BOARDED S DOCUMENT REQUIRED IF SELECTED FOR PHASE 2 X DOCUMENT NOT REQUIRED
NOTES: 1. Although DODMERB is not required until Phase 2 applicants should submit as soon as possible
2. CCF 104-R (WORKING) is just a best estimate by the Soldier and the ROTC program. Nosignatures are required other than the Soldier's. If selected to advance to Phase 2; CCF 104-R (FINAL)must be approved by the academic institution.
3. Only page 1 of CCF 145-1-6 is required for the Selection Board. If selected to advance tophase 2; page 1 must be updated (if required) and pages 2-3 must be completed and signed by theSchool of Choice.
4. Applicants applying for the Master’s Program who have not yet earned his/her degree may submitcurrent transcripts for Board consideration; however, if selected to advance to Phase 2, he/she mustsubmit a transcript with bachelor’s Degree conferred
17
18
19
SAMPLE
20
INSTRUCTIONS FOR COMPLETING CADET COMMAND FORM 174-R U.S. ARMY ROTC GREEN TO GOLD APPLICATION
ITEM REMARKS 1. Were You Ever DisenrolledFrom the ROTC Program
Enter “Yes” or “No”. Submit the DA 785 with the application (if applicable).
2. Select Option Self-explanatory 3. Degree Type
Scholarship CategorySelect from drop-down menu Can only apply for one option.
4. Rank Enter current rank. 5. Last Name Self-explanatory. 6. First Name Self-explanatory. 7. Middle Initial Self-explanatory. 8. Social Security Number Self-explanatory. 9. Date of Birth Select from drop down menu. 10. Contact Information:Home TelephoneCell NumberEmail Address (military)
Include area code and country code, if overseas.
Provide Enterprise Email address. 11. Current Home Address:
Street AddressApt.CityStateZip CodeCountry
Address where Soldier is physically living. Do not indicate HOR address unless currently living at that address.
12. Marital StatusSpouse MilitaryNumber of ChildrenCitizenship
Select from the drop-down menu.
13. Civil Convictions Enter either “Yes” or “No” Indicate “Yes” if Soldier has been arrested, indicted, or convicted of violating any civil or military law or had any adverse juvenile adjudication or other adverse disposition imposed except minor traffic violations for which a fine of $250.00 or less was imposed. List ALL convictions, even if expunged.
14. What is your Gender?Hispanic or Latino?Race
Self-explanatory. Self-explanatory. Enter Racial/Ethnic Descent
15. Unit of Assignment:Unit NameStreet AddressCITYSTATEZIPUnit Phone Number
Complete Unit Address i.e. HHC 1BN 4BDE 3ID1234 THIRD STi.e. FT KNOXEnter the two character abbreviation (ex., VA,AL, etc.)Include area code and country code, if overseas.
Basic Active Service Date Select from drop-down menu. Enlisted Expiration Date Select from drop-down menu. 20
21
MOS Self-explanatory. General Technical Aptitude Area Score (GT)
Self-explanatory (If GT score is less than 110, Soldiers are not eligible to complete application)
Favorable NACLC Select from drop-down menu. 16. Latest APFT (Date)
Push-UpsSit-Ups2-Mile Run
Select date from drop-down menu. Enter the exact score for each event. Do not enter number of repetitions. Soldiers on Permanent or Temporary Profiles are not eligible. Alternate events are not authorized.
17. HOST SCHOOL Select ROTC School from the drop-down menu. 18. Academic School Select Academic School from drop-down menu. Academic Major ADM Code CGPA Composite SAT/ACT SAT Equivalent
Select from Drop-down menu. Will auto-populate Enter CGPA established by the school attending. Only required for 4-yr applicants. Will auto-populate if required.
Box 1 Statement of Military Aptitude and Motivation
Must be completed by the current Company Commander
Attach a separate sheet of paper if more space is needed and include applicant’s full name, SSN and the item # you are completing (ex., Smith, John P., 123-45-6789, Item #1 continued).
Box 2. Statement of Performance and Potential
Must be completed by the current Company Commander.
Company Commander’s Recommendation
Select appropriate recommendation.
Is Soldier IAW AR 600-8-2 Select “Yes” or “No”. Grade Name of Company Commander Telephone Number Email Address
Enter 3-character rank. Enter full name. Enter area code and country code, if overseas. Enter Enterprise Email Address
Signature of Commanding Officer Sign Document. Ensure all items are complete before digitally signing. Cannot delete digital signature once signed.
Date Select date from drop-down menu. Box 3. Battalion Commander’s Recommendation
Select appropriate recommendation
Grade Name of Battalion Commander Telephone Number Email Address
Enter 3-character rank. Enter full name. Enter area code and country code, if overseas. Enter Enterprise Email Address
Signature of Battalion Officer Sign Document. Ensure all items are complete before digitally signing. Cannot delete digital signature once signed.
Date Select date from drop-down menu.
22
Box 4. Applicant’s Personal Statement - Must be completed
Requires a written or typed statement why Soldier desires a commission as an Army Officer. If additional space is required attach a separate sheet of paper and include Soldier’s full name, SSN and the item # completing (ex., Smith, John P., 123-45-6789, Item #Box 4. continued).
ACTIVE DUTY OPTION APPLICANTS ONLY
Read and Initial statements 1-14.
Signature of Green to Gold Applicant
Sign Document. Ensure all items are complete before digitally signing. Cannot delete digital signature once signed.
Date Select from drop-down menu.
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24
25
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INSTRUCTIONS FOR CALCULATING ITEM 5 - CC FORM 104-R
Credit Hoursa. Total required hours for degree 120
(Does not include ROTC)
(1) ROTC Hours that do not count 20(Include any ROTC hours that do not count towards the degree toensure academic and military alignment is maintained)
(2) Total Hours Required for NAPS 140(120 + 20)
17.50Normal Academic Progression(The form auto-calculates how many hours per semester/quarter would be required to obtain degree in 8 quarters/12 Semesters. Do not modify)
35
30
75
4
b. Credits towards degree completed to date (These are credits (if any) thathave been earned at the College/University the applicant plans to attendwhile enrolled in the program.)
c. Transfer Credits Accepted (These are credits earned at institutions otherthan the College/University the applicant plans to attend while enrolledin the program that are accepted by the university of choice)
d. Remaining for Degree([Total Hours Req for NAPS] - [Transfer credit accepted +Credits towards degree comp to date])Example: (140 - (35 + 30) = 75)
e. Number of authorized semesters(Remaining for Degree/Normal Academic Progression)Example: 75/17.50 = 4.28 (round down to 4)(Any fraction equal to or less than .5 will be rounded down to the lowerwhole number and anything greater than .5 will be rounded up to thenext higher whole number)
27
HOURS HOURS
TERM HOURS
5. Planned Academic Status upon Entry into the G2G Program (Sophmore,Junior, or Graduate)
4. Credits (if any) applicant plans to take or is currently taking between current date and entry into the G2G Program:
INSTITUTION NAME
6. SIGNATURE OF STUDENT: 7. DATE: (MM/DD/YYYY)
U.S. ARMY ROTC GREEN TO GOLD CREDIT TRANSFER EVALUATION
For use of this form, see USACC Reg 145-6, the proponent agency is ATCC-OIS
Authority
Principle Purpose
Routine Use
Disclosure
INSTITUTION NAME
DATA REQUIRED BY THE PRIVACY ACT OF 1974
10 USC 2102 and 2107.
Form is used to make transfer credits for the Green to Gold (G2G)program.
Form is used to obtain selection and eligibility information on applicants for thethe Green to Gold Program
Information provided on this form is mandatory, without the data provided on thisform, the application cannot be considered for participation in the program
INSTITUTION NAME
USACC FORM 145-1-6, JULY 2018
1. Academic School:
2. Applicant Last Name, First Name:
3. Summary of College Credits Complete to Date:
Page 1 of 3
28
Transferred Credits
INSTITUTION NAME COURSE NAME COURSE # GRADE HOURS18. Credits Transferred
USACC 145-1-6, JULY 2018 Page 2 of 3
29
Transferred Credits
INSTITUTION NAME COURSE NAME COURSE # GRADE HOURS19. Continuation Sheet
USACC 145-1-6, JULY 2018 Page 3 of 3
20. SIGNATURE OF SCHOOL OFFICIAL: 21. DATE: (MM/DD/YYYY)
30
INSTRUCTIONS FOR COMPLETING CC FORM 145-1-6
1. School applicant plans to attend while enrolled in the Program (School of choice)
2. Self‐Explanatory
3. College credit completed on the date the form is prepared. List Institution name and credits earned.JST credit (Intuition Name=JST) should also be listed here.
4. College credit applicant plans to take from time of submission of CC FORM 145‐1-6 to enrollment intothe program. List Institution, Term (Summer 20..ect…), and hours
5. ADO will be either Junior or Graduate.
6. Self‐Explanatory
THE ABOVE IS ALL THAT IS REQUIRED FOR THE SELECTION BOARD
If selected to Phase 2 Page 1 must be updated to show block 4 as none and pages 2‐3 must be completed and signed by the school of choice before a Fully Qualified letter will be issued.
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DD FORM 2808, 20190417
REPORT OF MEDICAL EXAMINATION1. DATE OF EXAMINATION
(YYYYMMDD)2a. SOCIAL SECURITY NUMBER
PRIVACY ACT STATEMENT AUTHORITY: 10 U.S.C. 504, Persons not qualified; 10 U.S.C. 505, Regular components: qualifications, term, grade; 10 U.S.C. 507, Extension of enlistment for members needing medical care or hospitalization; 10 U.S.C. 532, Qualifications for original appointment as a commissioned officer; 10 U.S.C. 978, Drug and alcohol abuse and dependency: testing of new entrants; 10 U.S.C. 1201, Regulars and members on active duty for more than 30 days: retirement; 10 U.S.C. 1202, Regulars and members on active duty for more than 30 days: temporary disability retired list; 10 U.S.C. 4346, Cadets: requirements for admission; DoD Directive 1145.2, United States Military Entrance Processing Command; and E.O. 9397 (SSN), as amended. PRINCIPAL PURPOSE(S): To obtain medical data for determination of medical fitness for enlistment, induction, appointment and retention for applicants and members of the Armed Forces. The information will also be used for medical boards and separation of Service members from the Armed Forces. ROUTINE USE(S): The Routine Uses are listed in the applicable system of records notice found at: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570661/a0601-270-usmepcom-dod/ DISCLOSURE: Voluntary; however, failure by an applicant to provide the information may result in delay or possible rejection of the individual's application to enter the Armed Forces. For an Armed Forces member, failure to provide the information may result in the individual being placed in a non-deployable status.3. LAST NAME - FIRST NAME - MIDDLE NAME
(Suffix)4. HOME ADDRESS (Street, Apartment Number, City, State and Zip Code)
5a. HOME TELEPHONE NUMBER (Include Area Code)
5b. E-MAIL ADDRESS
6. GRADE/ RANK
7. DATE OF BIRTH (YYYYMMDD)
8. AGE 9a. BIRTH SEX
Male
Female
9b. PREFERRED GENDER
Male
Female
10a. RACIAL CATEGORY (Select one)
American Indian or Alaska Native Asian
Black or African American White
Native Hawaiian or Other Pacific Islander
10b. ETHNIC CATEGORY
Hispanic/Latino
Non Hispanic/Latino
11. TOTAL YEARS GOVERNMENT SERVICE
a. MILITARY b. CIVILIAN12. AGENCY (Non-Service Members Only) 13. ORGANIZATION UNIT AND UIC/CODE
14a. RATING OR SPECIALTY (Aviators Only) 14b. TOTAL FLYING TIME 14c. LAST SIX MONTHS
15a. SERVICE
Army
Air Force
Marine Corps
Navy
Coast Guard
15b. COMPONENT
Active Duty
Reserve
National Guard
15c. PURPOSE OF EXAMINATION
Enlistment Retirement
Commission U.S. Service Academy
Retention ROTC Scholarship Program
Separation Medical Board
Other
16. NAME OF EXAMINING LOCATION, AND ADDRESS(Include Zip Code)
CLINICAL EVALUATION (Check each item in appropriate column. Enter "NE" if not evaluated.)
Normal Abnormal NE
17. Head, face, neck and scalp
18. Nose
19. Sinuses
20. Mouth and throat
21. Ears - General (Int. and ext. canals/Auditory acuity under item 71)
22. Drums (Perforation)
23. Eyes - General
24. Ophthalmoscopic
25. Pupils (Equality and reaction)
26. Ocular motility (Associated parallel movements, nystagmus)
27. Heart (Thrust, size, rhythm, sounds)
28. Lungs and chest (Include breasts)
29. Vascular system (Varicosities, etc.)
30. Anus and rectum (Hemorrhoids, Fistulae) (Prostate if indicated)
31. Abdomen and viscera (Include hernia)
32. External genitalia (Genitourinary)
33. Upper extremities
34. Lower extremities (Except feet)
35. Feet (Check category)
35a. Normal Arch Pes Planus Pes Cavus
35b. Mild Moderate Severe
35c. Asymptomatic Symptomatic
36. Spine, other musculoskeletal
37. Body marks, scars, tattoos
38. Skin, lymphatics
39. Neurologic
40. Psychiatric (Specify any personality deviation)
41. Pelvic (Females only)
42. Endocrine
43. DENTAL DEFECTS AND DISEASE(Please Explain - If abnormality noted, explain in Item 44.)
44. NOTES: (Mandatory comment for every abnormality identifiedin blocks 17 - 42. Enter pertinent item number before eachcomment. Continue comments or use drawings in 88 and useadditional sheets if necessary.)
2b. DoD ID NUMBER (If applicable)
41.
Normal
Abnormal
Not Evaluated
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DD FORM 2808, 20190417
LAST NAME - FIRST NAME - MIDDLE NAME (Suffix) SOCIAL SECURITY NUMBER DoD ID NUMBER
LABORATORY FINDINGS
45. URINALYSIS a. Albumin b. Sugar 46. URINE HCG 47. H/H 48. BLOOD TYPE
TESTS RESULTS
49. HIV
50. DRUGS
51. ALCOHOL
52. OTHER
a. PAP SMEAR
b. EKG
c. CXR
HIV SPECIMEN ID LABEL DRUG TEST SPECIMEN ID LABEL
MEASUREMENTS AND OTHER FINDINGS
53b. HEIGHT(STANDING, inches)
54. WEIGHT
lbs.
55a. MIN WGT 55b. MAX WGT 55c. MAX BF % 55d. BMI 56. TEMPERATURE 57. PULSE
58. BLOOD PRESSURE
a. 1ST b. 2ND c. 3RD
SYS. SYS. SYS.
DIAS. DIAS. DIAS.
59. RED/GREEN 60. OTHER VISION TEST
61. DISTANT VISION
Right 20/ Corr. to 20/
Left 20/ Corr. to 20/
62. REFRACTION BY MANIFEST REFRACTION
By S. CX
By S.
63. NEAR VISION
Right 20/ Corr. to 20/ By
Left 20/ Corr. to 20/ By
64. HETEROPHORIA (Specify distance)
ES EX R.H. L.H.Prismdiv.
Prism Conv CT
NPR PD
65. ACCOMMODATION
Right Left
66. COLOR VISION (Test used and score)
PIP FALANT
67. DEPTH PERCEPTION (Test and score/result)
AFVT FANDOT
68. FIELD OF VISION 69. NIGHT VISION (Test used and score) 70. INTRAOCULAR PRESSURE (Test and score/result)
O.D. O.S.
71a. AUDIOMETER Unit Serial Number
Date Calibrated (YYYYMMDD)
HZ 500 1000 2000 3000 4000 6000
Left
Right
71b. Unit Serial Number
Date Calibrated (YYYYMMDD)
HZ 500 1000 2000 3000 4000 6000
Right
Left
72a. READING ALOUD TEST:
SAT UNSAT
72b. VALSALVA:
SAT UNSAT
72c.OTHER TESTING
73. NOTES AND SIGNIFICANT OR INTERVAL HISTORY
53a. HEIGHT(SITTING, inches)
REPEATPULSE
NOT REQUIRED
USE ATTACHED EYE EXAMINATION FORM
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LAST NAME - FIRST NAME - MIDDLE NAME (Suffix) SOCIAL SECURITY NUMBER DoD ID NUMBER
74. EXAMINEE/APPLICANT
IS MEDICALLY QUALIFIED
IS NOT MEDICALLY QUALIFIED
75. I have been advised of my disqualifying condition(s).
75a. SIGNATURE OF EXAMINEE 75b. DATE (YYYYMMDD)
76. PHYSICAL MEDICAL PROFILE
P U L H E S X PROFILER INITIALS DATE (YYYYMMDD)
77. SIGNIFICANT OR DISQUALIFYING DEFECTS
ITEM NO. MEDICAL CONDITION/DIAGNOSIS ICD CODE PROFILE SERIAL
RBJ DATE (YYYYMMDD)
QUALIFIED DISQUALIFIED EXAMINER INITIALSWAIVER RECEIVED
SERVICE DATE (YYYYMMDD)
78. SUMMARY OF DEFECTS AND DIAGNOSES (List diagnoses with item numbers) (Use additional sheets if necessary).
79. RECOMMENDATIONS (Specify) (Use additional sheets if necessary).
80. MEPS WORKLOAD (For MEPS use only)
WKID ST DATE (YYYYMMDD) INITIALS WKID ST DATE (YYYYMMDD) INITIALS
81. MEDICAL INSPECTION DATE HT WT %BF MAX WT HCG QUAL DISQ EXAMINER'S NAME AND SIGNATURE
82a. TYPED OR PRINTED NAME OF PHYSICIAN OR EXAMINERb. Signature
83a. TYPED OR PRINTED NAME OF PHYSICIAN OR EXAMINERb. Signature
84a. TYPED OR PRINTED NAME OF DENTIST OR PHYSICIAN (Indicate which)b. Signature
85a. TYPED OR PRINTED NAME OF REVIEWING OFFICER/APPROVING AUTHORITY (Indicate which) b. Signature
86. This examination has been administratively reviewed for completeness and accuracy.
a. SIGNATURE b. GRADE c. DATE (YYYYMMDD)
87. WAIVER GRANTED (If yes, date and by whom)YES NO
88. NUMBER OF ATTACHED SHEETS
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89. NOTES, CONTINUATION AND SIGNIFICANT OR INTERVAL HISTORY
35
DD FORM 2807-2, OCT 2018
ACCESSIONS MEDICAL HISTORY REPORTOMB No. 0704-0413 OMB approval expires September, 30 2021
The public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, at [email protected]. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS.
PRIVACY ACT STATEMENTAUTHORITY: 10 U.S.C. 504, Persons not qualified; 10 U.S.C. 505, Regular components: qualifications, term, grade; 10 U.S.C. 507, Extension of enlistment for members needing medical care or hospitalization; 10 U.S.C. 532, Qualifications for original appointment as a commissioned officer; 10 U.S.C. 978, Drug and alcohol abuse and dependency: testing of new entrants; 10 U.S.C. 1201, Regulars and members on active duty for more than 30 days: retirement; 10 U.S.C. 1202, Regulars and members on active duty for more than 30 days: temporary disability retired list; 10 U.S.C. 4346, Cadets: requirements for admission; DoD Directive 1145.2, United States Military Entrance Processing Command; and E.O. 9397 (SSN), as amended.PRINCIPAL PURPOSE(S): To obtain medical data for determination of medical fitness for enlistment, induction, appointment and retention for applicants and members of the Armed Forces. The information will also be used for medical boards and separation of Service members from the Armed Forces.ROUTINE USE(S): The Routine Uses are listed in the applicable system of records notice found at: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570661/a0601-270-usmepcom-dod/DISCLOSURE: Voluntary, however, failure by an applicant to provide the information may result in delay or possible rejection of the individual's application to enter the Armed Forces. For an Armed Forces member, failure to provide the information may result in the individual being placed in a non-deployable status. WARNING: The information you have given constitutes an official statement. Federal law provides severe penalties (up to 5 years confinement or $10,000 fine, or both), to anyone making a false statement. If you are selected for enlistment, commission or entrance into a commissioning program based on a false statement, you may be subject to prosecution under the Uniform Code of Military Justice or to administrative separation proceedings for discharge, and could receive a less than honorable discharge.”
4.a. SOCIAL SECURITY NUMBER3. DATE OF BIRTH (YYYYMMDD)
b. DoD ID NUMBER(If applicable)
1. LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)
6. HEIGHT (inches) 9. DATE (YYYYMMDD)
12. USUAL OCCUPATION
8.a. SERVICE (X as applicable) b. COMPONENT (X as applicable)
10. PURPOSE OF EXAMINATION (X as applicable) 11. POSITION (If a current Federal Employee) (Job Title, Grade, Component)
5. (X one) 7. WEIGHT (lbs.)
2. AGE
SECTION I - APPLICANT
SECTION III - MEDICAL HISTORY. Check each item "Yes" or "No". All "Yes" items must be fully explained in Section IV (Pages 4 and 5).
Navy
ArmyMale
FemaleUSAF
Enlistment U.S. Service Academy
ROTC Scholarship
Other (Specify)
Commission
Retention
1. Double vision
5. Night blindness
4. Eye surgery to improve vision (RK, PRK, LASIK, etc.)
3. Cataracts or surgery for cataracts
2. Detached retina or surgery to repair a detached retina
USCG
Other:
USMC
National Guard
Reserve Component
Regular
CURRENTLY HAVE OR ANY HISTORY OF:
EYES
NOYESCURRENTLY HAVE OR ANY HISTORY OF:YES NO
a. SEX (at birth) b. GENDER
Male
Female
6. Glaucoma
EYES (Continued)
SECTION II - AUTHORIZATION STATEMENTI (we), the undersigned: l Have read and understand the warning and penalties that are associated with providing a false statement. l Certify the information on this form is true and complete to the best of my knowledge and belief, and no person has advised me to conceal or falsify any information about my
physical and mental history. l Authorize and understand that a physical examination is part of the accession evaluation, may require several visits to the Military Entrance Processing Station (MEPS), and
Department of Defense Medical Examination Review Board (DoDMERB) contracted medical centers and that I may have blood work and/or other medical tests, procedures and/or specialty consultations performed as part of my processing. I understand that the results of the examination, tests, and consults will be reviewed and considered as part of my application file and are not performed as part of an individual healthcare treatment plan. The MEPS/DoDMERB medical staff are not my healthcare providers. If I do not receive notice of an abnormal test or consult, I am not to assume that the results are normal. Furthermore, if any test or consult results are abnormal, I am responsible for obtaining those results from the MEPS and for any necessary follow-up evaluations and/or treatment. If I am notified to return to the MEPS to discuss medical results, it is my responsibility to take quick action to return to the MEPS/DoDMERB to speak with the Chief Medical Officer (CMO). Any concerns that I have about my health and healthcare are my responsibility to address with my personal healthcare provider(s).
l Understand that neither USMEPCOM or DoDMERB are financially responsible for costs associated with any necessary follow-up evaluations and/or treatment based on my screening evaluation. Any concerns that I have about my health and healthcare are my responsibility to address with my personal healthcare provider(s)
l Understand that I must provide required documentation regarding my health history which, upon my accession, will become part of my Service member lifecycle medical treatmentrecord.
l I agree that all personal information or data disclosed by myself or others on my behalf with my consent during this process may be further disseminated as needed during the accession process and that my medical information is no longer protected by federal Health Insurance Portability and Accountability Act (HIPAA) Privacy Rules.
l Authorize release of records and information relating to grades, performance, individual education plans, and disciplinary proceedings. Under the Family Educational Rights andPrivacy Act (FERPA) USMEPCOM/DoDMERB is authorized to receive all my education/disciplinary records for evaluation of my acceptability for Service in the Armed Forces.
l Understand that I have the right to refuse to sign this authorization but also understand that failure to do so may cause me to be found disqualified for further processing. l Understand this authorization will expire four years from the date of the signature below or sooner if written request is received by USMEPCOM/DoDMERB Staff Judge Advocate's
Office. I have the right to revoke this authorization in writing, except to the extent that the DoD has acted in reliance on this information.
1. APPLICANT
a. Signature b. Date Signed (YYYYMMDD)
2. PARENT OR GUARDIAN SIGNATURE IS MANDATORY FOR MINOR APPLICANT, SIGNATURE IS OPTIONAL IF APPLICANT IS OF AGE
a. Name (Last, First, Middle Initial) b. Signature c. Date Signed (YYYYMMDD)
3. RECRUITING REPRESENTATIVE: (If a representative was used) I certify all information is complete and true to the best of my knowledge.
a. Name (Last, First, Middle Initial) b. Recruiter Identification Number c. Signature d. Date Signed (YYYYMMDD)
36
DD FORM 2807-2, OCT 2018
SOCIAL SECURITY NUMBER (Last 4)LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)
SECTION III - MEDICAL HISTORY (Continued). Check each item "Yes" or "No". All "Yes" items must be fully explained in Section IV.
48. A change of menstrual pattern (other than pregnancy)
50. Any abnormal PAP smear(s)
52. Diagnosed with endometriosis or ovarian cysts
54. Sexually transmitted disease (syphilis, gonorrhea, chlamydia,genital warts, herpes, etc.)
59. Sexually transmitted disease (syphilis, gonorrhea, chlamydia,genital warts, herpes, etc.)
53. Evaluation, treatment or surgery for any other gynecological(female) disorder
51. Date of last PAP smear (YYYYMMDD)
55. First day of last menstrual period (YYYYMMDD)
49. Pregnancy, abortion or miscarriage
CURRENTLY HAVE OR ANY HISTORY OF:
FEMALES ONLY:
56. Missing a testicle, testicular implant, or undescended testicle
58. Prostate problems
57. Variocele, hydrocele, or any scrotal mass, swelling or pain
MALES ONLY:
60. Missing a kidney
65. Bedwetting or treatment for bedwetting (previous 12 months)
66. Hernia
64. Painful or difficult urination
63. Blood or protein in urine
62. Kidney or urinary tract surgery of any kind
61. Kidney stone, infection or disease
URINARY SYSTEM
67. Back pain or back problem
71. Abnormal curvature of your spine (any part)
70. Back or neck surgery
69. Neck pain
68. Herniated disk
SPINE AND SACROILIAC JOINTS
72. Painful shoulder, elbow, wrist, hand or fingers
73. Dislocated shoulder, elbow, wrist, hand or fingers
UPPER EXTREMITIES
78. Bone, joint, or other orthopedic deformity
79. Loss of finger or toe, or extra finger or toe
83. Any swollen joint(s)
82. Arthritis, rheumatism, gout, or bursitis
81. Impaired use of arms, hands, legs, or feet (any reason)
80. Loss of the ability to fully flex (bend) or fully extend a finger, toe,or other joint
MISCELLANEOUS CONDITIONS OF THE EXTREMITIES
74. Foot trouble (e.g., pain, corns, bunions, warts, ingrown toenails, etc.)
75. Knee trouble (e.g., locking, giving out, or ligament injury, etc.)
77. Dislocated hip, knee, ankle, foot or toes
76. Painful hip, knee, ankle, foot or toes
LOWER EXTREMITIES
NOYESCURRENTLY HAVE OR ANY HISTORY OF:YES NO
DoD ID NUMBER (If applicable)
84. Surgery on any joint/bone (including arthroscopy)
85. Plate(s), screw(s), rod(s) or pin(s) in any bone
86. Pain or swelling at the site of an old fracture
87. Any need to use corrective devices such as prosthetic devices,knee brace(s), back support(s), lifts or orthotics
88. Any other orthopedic, muscle, or sports injury problems
VASCULAR
89. High or low blood pressure
90. Raynaud's phenomenon or disease
91. Deep Vein Thrombosis (blood clot; leg or elsewhere)
92. Pulmonary embolism (blood clot in lung)
ABDOMINAL ORGANS AND GASTROINTESTINAL SYSTEM
37. Stomach, esophageal or intestinal ulcer
38. Difficulty swallowing
39. Frequent indigestion or heartburn
40. Gall bladder trouble or gallstones
41. Jaundice (except neonatal) or hepatitis (liver disease)
42. Rupture/hernia
43. Surgery to remove or repair a portion of the intestine or spleen(other than the appendix)
44. Chronic or recurrent intestinal problem of the small or largebowel such as Irritable Bowel Syndrome, Crohn's disease, Ulcerative Colitis, or Celiac disease
45. Rectal disease, hemorrhoids, or blood from the rectum
46. Hemorrhoid surgery
47. Bariatric surgery (weight loss surgery)
22. Asthma
23. Wheezing
24. Shortness of breath
25. Bronchitis
26. Other breathing problems worsened by exercise, weather,pollens, etc.
27. Used inhaler(s) or steroids for breathing problem(s)
28. Chronic cough or frequent coughing at night
30. History of chest, chest wall, or breast surgery
29. Collapsed lung or other lung condition
HEART
31. Heart murmur, valve problem or mitral valve prolapse
32. Palpitation, pounding heart or abnormal heartbeat
33. Heart surgery
34. Pain or pressure in the chest
35. An abnormal electrocardiogram (EKG)
36. Any other heart problems
LUNGS, CHEST WALL, PLEURA, AND MEDIASTINUM
DENTAL
20. Do you wear dental braces or Invisalign, or plan to wear braces orInvisalign?
21. Tooth or gum problems (other than cavities)
HEARING
15. Hearing loss or wear a hearing aid
NOSE, SINUSES, MOUTH, AND LARYNX
16. Ear, nose, or throat trouble including tonsillectomy
17. Chronic sinus infections or recurrent nose bleeds
18. Absence of, or disturbance of sense of smell
19. Any surgery of your face, mandible or jaw
VISION
9. Worn/wear contact lenses or glasses (Bring your eyeglasses nomatter how old they are.)
10. Loss of vision in either eye
11. Color vision deficiency or color blindness
EARS
12. Perforated ear drum or tubes in ear drum(s)
13. Ear surgery, to include mastoidectomy or repair of perforatedear drum
14. Loss of balance or vertigo
7. Strabismus or "lazy eye" or any surgery to correct these
8. Any other eye condition, injury or surgery
EYES (Continued)
37
DD FORM 2807-2, OCT 2018
SOCIAL SECURITY NUMBER (Last 4)LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)
SECTION III - MEDICAL HISTORY (Continued). Check each item "Yes" or "No". All "Yes" items must be fully explained in Section IV.
CURRENTLY HAVE OR ANY HISTORY OF: NOYESCURRENTLY HAVE OR ANY HISTORY OF:YES NO
LEARNING, PSYCHIATRIC, AND BEHAVIORAL (Continued)
141. Anorexia, bulimia, or other eating disorder
145. Used illegal drugs or abused prescription drugs
146. Have you been evaluated, treated, or hospitalized for substance abuse, addiction or dependence (including illegal drugs,prescription medications or other substances)
147. Have you been evaluated, treated, or hospitalized for alcoholabuse, dependence, or addiction
148. Post-traumatic Stress Disorder or excessive stress requiring counseling and/or medication following a traumatic experience
144. Have you ever attempted or considered suicide
143. Have you ever purposely cut or harmed yourself
142. Habitual stammering or stuttering
151. Cold injury, frostbite or cold intolerance
152. Heat injury, heat stroke or heat intolerance
MISCELLANEOUS
153. Are you taking any medications, to include over the countermedications (OTCs), vitamin, herbal, or nutritional supplements(If "yes", list all in Section IV.)
156. Have you ever had any illness or injury other than those already noted? (If "yes", specify when, where and give details inSection IV.)
SUPPLEMENTAL QUESTIONS
157. Have you ever been treated in an Emergency Room? (If "yes",explain in Section IV.)
160. Have you ever been rejected for military Service for anyreason? (If "yes", give date and reason in Section IV.)
161. Have you ever been discharged from the military Service forany reason? (If "yes", give date, reason, and type of discharge,whether honorable, other than honorable, for unfitness or unsuitability in Section IV.)
162. Have you ever been refused employment or been unable tohold a job or stay in school because of any of the following:(If "yes", answer a - d below and give reasons in Section IV.)
163. Applied for and/or received disability evaluation and/orcompensation for an injury or other medical conditions(If "yes", provide details in Section IV.)
164. Have you ever been denied life insurance? (If "yes", provide reason(s) in Section IV.)
a. Sensitivity to chemicals, dust, sunlight, etc.
d. Other medical reasons
c. Inability to stand, sit, kneel, lie down, etc.
b. Inability to perform certain motions
159. Have you ever had, or have you been advised to have any operations or surgery? (If "yes", describe and give age at which occurred in Section IV.)
158. Have you ever been a patient in any type of hospital (including being kept overnight)? (If "yes", specify when, where, why, andname of doctor and complete address of hospital in Section IV.)
140. Nervous trouble of any sort (anxiety or panic attacks)
139. Been evaluated or treated, either with medication or counseling,for a mental condition, depression or excessive worry
136. Been expelled or suspended from school
138. Been arrested or other encounters with law enforcement
137. Been kicked out or removed from your home
DoD ID NUMBER (If applicable)
149. Any other learning, psychiatric, or behavioral problems
TUMORS AND MALIGNANCIES
150. Tumor, growth, cyst, or cancer of any type
LEARNING, PSYCHIATRIC, AND BEHAVIORAL
131. Evaluated or treated for Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD)
132. Taken (or taking) medication, drugs, or any substance toimprove attention, behavior, or physical performance
133. Diagnosed with a learning disorder, to include dyslexia
134. Received counseling of any type
135. Seen a psychiatrist, psychologist, social worker, counselor or other professional for any reason (inpatient or out-patient) including counseling or treatment for school, adjustment, family,marriage, divorce, depression, anxiety, or treatment of alcohol, drug or substance abuse (Applicant or recruiter will requestsealed medical supporting documents from health care pro-
viders marked "CONFIDENTIAL: MEPS MEDICAL DEPART- MENT" and submit directly to MEPS medical personnel.)
NEUROLOGIC
115. Cerebrovascular incident (stroke)
118. Lost time from work or school due to frequent or severe headaches
119. A skull fracture
120. A head injury, memory loss, or amnesia
121. A period of unconsciousness or concussion
122. Loss of memory or amnesia, or neurological symptoms
123. Paralysis
124. Meningitis, encephalitis, or other neurological problems
125. Seizures, convulsions, epilepsy or fits
126. Dizziness or fainting spells
127. Any other neurologic problems
SLEEP DISORDERS
128. Sleepwalking or narcolepsy
129. Frequent trouble sleeping
130. Sleep apnea or severe snoring
116. Frequent or severe headaches, including migraines
117. Taking medication to prevent headaches
107. Tuberculosis or lived with someone who had tuberculosis
SYSTEMIC
103. Adverse reaction to medication (describe reaction in Section IV)
104. Adverse reaction to serum, insect bites, or stings
105. Allergy to foods (milk, eggs, fish, meat, nuts, etc.)
106. Allergy to wool, latex, or other material
108. Positive test for tuberculosis (PPD or blood test)
109. Malaria
110. Disorder(s) of your immune system (including HIV)
111. Car, train, sea, or air sickness
ENDOCRINE AND METABOLIC
112. Thyroid trouble or goiter
113. High or low blood sugar
114. Diabetes or told that you should be tested for diabetes
96. Large or painful scars
BLOOD AND BLOOD FORMING TISSUES
95. Psoriasis
94. Atopic dermatitis or Eczema
97. Any other skin problems
98. Anemia (iron deficiency, sickle cell, thalassemia)
99. Blood clots requiring blood thinner medicine
100. Absence or removal of the spleen
101. Prolonged bleeding (after an injury or tooth extraction)
102. Any other blood or circulation problems
93. Acne
SKIN AND CELLULAR
155. Artificial or replacement body part (eye, bone, palate, hip, knee,joint, leg, arm, etc.)
154. Any recent unexplained gain or loss of weight
38
DD FORM 2807-2, OCT 2018
SECTION IV - APPLICANT COMMENTS. Explain all "Yes" answers to questions 1 - 164 above.Begin with the Item Number. Describe answer(s) fully: provide date(s) of problem(s)/condition(s); provide names of Health Care Providers (HCPs), Clinic(s) and/or Hospital(s) along with the City and State; explain what was done (e.g., evaluation and/or treatment); and describe your current medical status. Attach additional sheet(s) if necessary and sign and date each additional page. Obtain and attach copies of applicable medical evaluation and treatment records.
SOCIAL SECURITY NUMBER (Last 4)LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX) DoD ID NUMBER (If applicable)
39
DD FORM 2807-2, OCT 2018
SOCIAL SECURITY NUMBER (Last 4)LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX) DoD ID NUMBER (If applicable)
SECTION V - HEALTH CARE PROVIDER/INSURANCE CARRIER CONTACT INFORMATION: Current Primary Care Physician(s)/Practitioner(s) and/or Clinic(s) where care is received and Current/Previous Insurance Carrier(s) information.Attach additional sheets if necessary.
c. TELEPHONE (Include Area Code)b. ADDRESS (Include ZIP Code)a. NAME(S)
1. CURRENT PRIMARY CARE PHYSICIAN(S)/PRACTITIONER(S) AND/OR CLINIC(S)
c. TELEPHONE (Include Area Code)b. ADDRESS (Include ZIP Code)a. NAME(S)
2. PREVIOUS PRIMARY CARE PHYSICIAN(S)/PRACTITIONER(S) AND/OR CLINIC(S)
c. TELEPHONE (Include Area Code)b. ADDRESS (Include ZIP Code)a. NAME(S)
3. CURRENT INSURANCE AND/OR PHARMACY BENEFIT MANAGER(S)
c. TELEPHONE (Include Area Code)b. ADDRESS (Include ZIP Code)a. NAME(S)
4. PREVIOUS INSURANCE AND/OR PHARMACY BENEFIT MANAGER(S)
5.
a. NAME(S) b. ADDRESS (Include ZIP Code) c. TELEPHONE (Include Area Code)
40
DD FORM 2807-2, OCT 2018
SOCIAL SECURITY NUMBER (Last 4)LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX) DoD ID NUMBER (If applicable)
7. Applicant
a. Signature b. Date Signed (YYYYMMDD)
8. Parent or Guardian Signature is mandatory for minor applicant, signature is optional if applicant is of age
a. NAME (Last, First, Middle Initial) b. Signature c. Date Signed (YYYYMMDD)
3. I authorize the release of the medical records that I marked above through an electronic health exchange if available.
4. I understand that if the person or agency that receives my information is not a health care provider or health plan covered by the HIPAA privacyregulations, the information described above may be redisclosed and is no longer protected by these regulations.
5. This authorization for medical records release will expire no later than 2 years from the date of signature or as directed by local laws. I understandwritten notification is necessary to cancel this authorization before such date and can be addressed to the department listed at item 2 of this form. Iam aware that my cancellation will not be effective as to disclosures already made in reference to this authorization.
6. I understand that this disclosure may include information regarding drug abuse, alcoholism, or alcohol abuse, psychiatric or mental illness,Acquired Immunodeficiency Syndrome (AIDS) or infection with HIV regulated by Federal Statute (42 CFR Part 2).
1. I authorize the release of the following information by ALL holders of my medical records/information (check all applicable) Choosing not to release all recordswill delay medical qualification determination.
All records Abstract Inpatient medical records
Outpatient medical records Laboratory/pathology records X-ray films/radiology records
Billing records Pharmacy/prescription records Psychotherapy/psychiatic care records
HIV, drug, and/or alcohol use records Other
Applicant (Patient) Name: Social Security Number:
SECTION VI - MEDICAL RECORDS RELEASE
Date of Birth (MM/DD/YYYY) Phone: Address:
Describe specifically:
2. Please send my records listed above to:
Name: Address:
Phone: Fax:
41
DD FORM 2807-2, OCT 2018
SECTION VII - MEDICAL PROVIDER'S SUMMARY AND DESCRIPTION OF PERTINENT INFORMATION: Review and comment on all medical records, electronically provided medical history information, and other electronic data available in the Department of Defense Accessions Processing System. Medical providers may also develop any additional medical history deemed important and record significant findings here or by interview and document them on DD Form 2808, "Report of Medical Examination". Attach additional sheet(s) if necessary.
COMMENTS:
LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX) SOCIAL SECURITY NUMBER (Last 4) DoD ID NUMBER (If applicable)
42
DD FORM 2807-2, OCT 2018
LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX) SOCIAL SECURITY NUMBER (Last 4) DoD ID NUMBER (If applicable)
SECTION VIII - MEDICAL PROVIDER'S PRESCREEN DETERMINATION BASED ON AVAILABLE INFORMATION:c. IF NOT WITHIN STANDARDS:
ICD CONDITION PULHES SMWRA INPUTd. PROVIDER
INITIALSb. MEDICAL PROCESSING STATUS1.a. DATE
(YYYYMMDD) PA PRW PH RJ METR PNJ
KEY: PA = Processing Authorized; PRW = Processing Requested by SMWRA; PH = Processing Hold; RJ = Return Justified; METR = Medical Evaluation and/or Treatment Records; PNJ = Processing Not Justified; ICD = International Classification of Disease Code; PULHES = P (Physical Capacity), U (Upper Extremities),
L (Lower Extremities), H (Hearing), E (Eyes), S (Psychiatric); SMWRA = Service Medical Waiver Review Authority.
2. *FOR MEPS USE ONLY:
ON EXAM: a. PSN COMP b. PSN INCOM c. NPS d. *AE e. *RE f. *ME g. *OE h. DATE(YYYYMMDD)
i. PROVIDERINITIALS
3. AUTHORIZING MEDICAL PROVIDER
a. NAME (Last, First, Middle Initial) b. SIGNATURE c. DATE SIGNED (YYYYMMDD)
4. EXAMINING PROVIDER
a. NAME (Last, First, Middle Initial) b. SIGNATURE c. DATE SIGNED(YYYYMMDD)
5. NUMBER OF ADDITIONALSHEETS SUBMITTED
43
DoD Medical Examination Review Board 8034 Edgerton Drive, Suite 132
USAF Academy, Colorado 80840-2200
EYE EXAMINATION FORM
NAME: _______________________________________________SOCIAL SECURITY NUMBER: _________-_______-_________
Applicant, please complete PART A. In accordance with the instructions provided within your remedial request letter, take this form to the eye clinic for the examination(s) requested by DoDMERB and have the optometrist/ophthalmologist complete PART B and return the completed form to DoDMERB at the above address. ___________________________________________________________________________________________________________
PRIVACY ACT STATEMENT AUTHORITY: Title 10, USC 133, 3012, 5031, 8013, and Executive Order 9397 PRINCIPAL PURPOSE: To determine medical acceptability or update a medical file as part of the application process to a United States Service Academy, Reserve Officer Training Corp (ROTC) Scholarship Program, or the Uniformed Services University of the Health Sciences (USUHS). ROUTINE USES: This information may be disclosed to the Coast Guard Academy and Merchant Marine Academy for applicants to their Academies. DISCLOSURE: Voluntary; however, failure to furnish the requested information will impede the selection process and hamper your candidacy. Use of the Social Security Number (SSN) is used for positive identification of records. ______________________________________________________________________________________________________________________________________ PART A
1) Please circle the appropriate answer about contact lenses: I DO / DO NOT wear contact lenses.2) If applicable, the lenses I wear are (please circle the appropriate answer below about contact lenses):
SOFT / RIGID - HARD / RIGID for ortho-keratology or corneal refractive therapy
3) My contact lenses have not been worn “at all” for ___________________ days prior to the exam in PART B.4) I certify the above information about my contact lens use prior to the PART B exam is true and accurate to the best of my knowledge.
_________________________________________ _____________________ Applicant’s Signature Date
______________________________________________________________________________________________________________ PART B
Eye Examination Data
If Red Lens Test (#26 above) is failed with Diplopia, please specify which position(s) of gaze: __________________________________ For Cyploplegic Refractions only, the type of medication and regimen used:_________________________________________________
___________________________________ ________________ Doctor’s Signature/Stamp Date
Eye Examination Form
44
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Age Waivers ADO (30-32) X X X X X X Age Waivers ADO (33-39) X X X X X X
Age Waivers ADO (40+) X X X X X X Civil Conviction - Minor Traffic
-fine less than $250 (6 or more within 12 months) X X X X X X X X
-fine more than $250 X X X X X X X X -fine of $100 or more per offense, plus other adverse
adjudication (6 or more within 12 months) or (10 or more
in previous 3 years) X X X X X X X X
Civil Conviction - Minor Non-Traffic
-fine less than $250 X X X X X X X X -fine over $250 X X X X X X X X
Civil Conviction - Minor Traffic & Non-Traffic*
Any adverse disposition that included a sentence of
jail/confinement/detention, even if suspended X X X X X X X X
Minor Traffic and Non-Traffic Civil Convictions - any
adverse disposition that included a sentence of
jail/confinement/detention. Other misdemeanors.
Misconduct (Convictions for felonies or offenses that
involve moral turpitude
X X X X X X X X
College Board Score (ACT/SAT) X X X X X Cumulative Grade Point Average (CGPA) X X X X X X Re-enrollment X X X X X X X Dependency Waivers (Electronic):
More than 3 dependents X X X X X X
Dual Military (with dependents)/Dual ROTC X X X X
Non-Custodial parent (child support only) X X X X X
Sole parent/Joint Custody X X X X X X X X Exceptions to Policy
AFS 10 years or more X X X X X X Training Service Obligation* X X X X X X
Time In Service (less the 2 years)* X X X X X X
* TIS/TSO and Civil Conviction (USACC CG Approval) MUST be submitted as soon as the applicant starts theapplication process. All other waivers should be submitted AFTER the Soldier is selected for the program** DA Form 4187s should be uploaded in the online application AFTER all digital signatures (up to BDE CDR)are received. Please do not email waivers requests and associated documents to the RMID staff.*** Supporting Documents listed are for situational awareness only. These documents should be uploadedin the Green to Gold portal by the applicant. Do not send these documents with the 4187.
Supporting Documents ***Waiver Authority
Green to Gold Waiver Authority Matrix
45
HQ, CADET COMMANDATTN: RMID (Green to Gold)204 1st Cavalry Regiment RoadFort Knox, KY 40121
COMMANDER(ROTC BDE Information)
Professor of Military Science(Program Information)
Applicant's Name Applicant's Rank/MOS Applicant's SSN
Age Waiver
1. Soldiers required an Age Waiver approved at ROTC BDE Level for participation in the Green to Gold program whenthat Soldier will be 30-32 years of age at time of commissioning
2. (Soldier's RANK Name) will be________ years and________months of age at projected time of commission andtherefore requests an Age Waiver
PMS RANK/NAME PMS SIGNATURE DATE
Sample Request for Age Waiver (Age 30-32 BDE CDR Authority)
46
Applicant's Name Applicant's SSN
HQ, USACC, ATTN: RMID (Green to Gold) 204 1st Cavalry Regiment RoadFort Knox, KY 40121
COMMANDER(ROTC BDE Information)
ROTC BDE CDR NAME ROTC BDE CDR RANK DATE
Commander ROTC BDE CDR SIGNATURE
47
HQ, CADET COMMANDATTN: RMID (Green to Gold)204 1st Cavalry Regiment RoadFort Knox, KY 40121
COMMANDER(ROTC BDE Information)
Professor of Military Science(Program Information)
Applicant's Name Applicant's Rank/MOS Applicant's SSN
Age Waiver
1. Soldiers required an Age Waiver approved at USACC CG Level for participation in the Green to Gold program whenthat Soldier will be 33-39 years of age at time of commissioning
2. (Soldier's RANK Name) will be________ years and________months of age at projected time of commission andtherefore requests an Age Waiver
PMS RANK/NAME PMS SIGNATURE DATE
Sample Request for Age Waiver (Age 33-39 USACC CG Authority)
48
Applicant's Name Applicant's SSN
COMMANDER, USACC204 1st Cavalry Regiment RoadFort Knox, KY 40121
COMMANDER(ROTC BDE Information)
ROTC BDE CDR NAME ROTC BDE CDR RANK DATE
Commander ROTC BDE CDR SIGNATURE
HQ, USACC, ATTN: RMID (Green to Gold)204 1st Cavalry Regiment RoadFort Knox, KY 40121
COMMANDER, USACC204 1st Cavalry Regiment RoadFort Knox, KY 40121
USACC CG CDR NAME USACC CG CDR RANK
Commanding General USACC CG SIGNATURE
DATE
49
HQ, CADET COMMANDATTN: RMID (Green to Gold)204 1st Cavalry Regiment RoadFort Knox, KY 40121
COMMANDER(ROTC BDE Information)
Professor of Military Science(Program Information)
Applicant's Name Applicant's Rank/MOS Applicant's SSN
Age Waiver
1. Soldiers required an Age Waiver approved at HQDA Level for participation in the Green to Gold program when thatSoldier will be 40-42 years of age at time of commissioning
2. (Soldier's RANK Name) will be________ years and________months of age at projected time of commission andtherefore requests an Age Waiver
PMS RANK/NAME PMS SIGNATURE DATE
Sample Request for Age Waiver (Age 40-42 HQDA Authority)
50
Applicant's Name Applicant's SSN
COMMANDER, USACC204 1st Cavalry Regiment RoadFort Knox, KY 40121
COMMANDER(ROTC BDE Information)
ROTC BDE CDR NAME ROTC BDE CDR RANK DATE
Commander ROTC BDE CDR SIGNATURE
HQ, USACC, ATTN: RMID (Green to Gold)204 1st Cavalry Regiment RoadFort Knox, KY 40121
COMMANDER, USACC204 1st Cavalry Regiment RoadFort Knox, KY 40121
USACC CG CDR NAME USACC CG CDR RANK
Commanding General USACC CG SIGNATURE
DATE
51
HQ, CADET COMMANDATTN: RMID (Green to Gold)204 1st Cavalry Regiment RoadFort Knox, KY 40121
COMMANDER(ROTC BDE Information)
Professor of Military Science(Program Information)
Applicant's Name Applicant's Rank/MOS Applicant's SSN
Civil Conviction Waiver
1. Soldiers require a Civil Conviction Waiver approved at ROTC BDE level for participation in the Green to GoldProgram when that Soldier has received a Civil Conviction consisting of a punishment of fine only (even if expunged):
2. (Applicant's Rank/Name) is requesting a Civil Conviction waiver for (list offense and fine).
3. Additional Information
PMS RANK/NAME PMS SIGNATURE DATE
Sample Request for Civil Conviction Waiver ( ROTC BDE CDR Authority)
52
Applicant's Name Applicant's SSN
HQ, USACC, ATTN: RMID (Green to Gold) 204 1st Cavalry Regiment RoadFort Knox, KY 40121
COMMANDER(ROTC BDE Information)
ROTC BDE CDR NAME ROTC BDE CDR RANK DATE
Commander ROTC BDE CDR SIGNATURE
53
HQ, CADET COMMANDATTN: RMID (Green to Gold)204 1st Cavalry Regiment RoadFort Knox, KY 40121
COMMANDER(ROTC BDE Information)
Professor of Military Science(Program Information)
Applicant's Name Applicant's Rank/MOS Applicant's SSN
Civil Conviction Waiver
1. Soldiers require a Civil Conviction Waiver approved at USACC CG level for participation in the Green to GoldProgram when that Soldier has received a Civil Conviction consisting of a punishment other than simple fine (even ifexpunged):
2. (Applicant's Rank/Name) is requesting a Civil Conviction waiver for (list offense and fine).
3. Additional Information
PMS RANK/NAME PMS SIGNATURE DATE
Sample Request for Civil Conviction Waiver (USACC CG Authority)
54
Applicant's Name Applicant's SSN
COMMANDER, USACC204 1st Cavalry Regiment RoadFort Knox, KY 40121
COMMANDER(ROTC BDE Information)
ROTC BDE CDR NAME ROTC BDE CDR RANK DATE
Commander ROTC BDE CDR SIGNATURE
HQ, USACC, ATTN: RMID (Green to Gold)204 1st Cavalry Regiment RoadFort Knox, KY 40121
COMMANDER, USACC204 1st Cavalry Regiment RoadFort Knox, KY 40121
USACC CG CDR NAME USACC CG CDR RANK
Commanding General USACC CG SIGNATURE
DATE
55
HQ, CADET COMMANDATTN: RMID (Green to Gold)204 1st Cavalry Regiment RoadFort Knox, KY 40121
COMMANDER(ROTC BDE Information)
Professor of Military Science(Program Information)
Applicant's Name Applicant's Rank/MOS Applicant's SSN
Standardized Test Score (SAT/ACT)
1. Soldiers required a Standardized Test Score Waiver approved at the USACC CG Level for participation in the Green toGold program when that Soldier has a SAT score below 1000 (920 if the test was taken prior to 03/01/2016) or an ACTscore below 19.
2. (Soldier's RANK Name) has a (SAT/SAT) score of________ and therefore requests a Standardized Test Score Waiver
PMS RANK/NAME PMS SIGNATURE DATE
Sample Request for Standardized Test Scores Waiver (USACC CG Authority)
56
Applicant's Name Applicant's SSN
COMMANDER, USACC204 1st Cavalry Regiment RoadFort Knox, KY 40121
COMMANDER(ROTC BDE Information)
ROTC BDE CDR NAME ROTC BDE CDR RANK DATE
Commander ROTC BDE CDR SIGNATURE
HQ, USACC, ATTN: RMID (Green to Gold)204 1st Cavalry Regiment RoadFort Knox, KY 40121
COMMANDER, USACC204 1st Cavalry Regiment RoadFort Knox, KY 40121
USACC CG CDR NAME USACC CG CDR RANK
Commanding General USACC CG SIGNATURE
DATE
57
HQ, CADET COMMANDATTN: RMID (Green to Gold)204 1st Cavalry Regiment RoadFort Knox, KY 40121
COMMANDER(ROTC BDE Information)
Professor of Military Science(Program Information)
Applicant's Name Applicant's Rank/MOS Applicant's SSN
CGPA Waiver
1. Soldiers required a Consolidated Grade Point Average (CGPA) Waiver approved at the USACC CG Level forparticipation in the Green to Gold program when that Soldier has a CGPA between 2.00-2.49.
2. (Soldier's RANK Name) has a CPGA of________ and therefore requests a CPGA Waiver
PMS RANK/NAME PMS SIGNATURE DATE
Sample Request for Consolidated Grade Point Average Waiver (USACC CG Authority)
58
Applicant's Name Applicant's SSN
COMMANDER, USACC204 1st Cavalry Regiment RoadFort Knox, KY 40121
COMMANDER(ROTC BDE Information)
ROTC BDE CDR NAME ROTC BDE CDR RANK DATE
Commander ROTC BDE CDR SIGNATURE
HQ, USACC, ATTN: RMID (Green to Gold)204 1st Cavalry Regiment RoadFort Knox, KY 40121
COMMANDER, USACC204 1st Cavalry Regiment RoadFort Knox, KY 40121
USACC CG CDR NAME USACC CG CDR RANK
Commanding General USACC CG SIGNATURE
DATE
59
HQ, CADET COMMANDATTN: RMID (Green to Gold)204 1st Cavalry Regiment RoadFort Knox, KY 40121
COMMANDER(ROTC BDE Information)
Professor of Military Science(Program Information)
Applicant's Name Applicant's Rank/MOS Applicant's SSN
Reenrollment Waiver
1. Soldiers required a Reenrollment Waiver approved at ROTC BDE Level for participation in the Green to Goldprogram when that Soldier was previously disenrolled from either the Army ROTC Basic Course or Advance Course.
2. (Soldier's RANK Name) information:
a. Date of Disenrollment- b. MS Level at time of Disenrollment- c. Reason for Disenrollment- d. Remaining Service or Scholarship debts-
PMS RANK/NAME PMS SIGNATURE DATE
Sample Request for Reenrollment Waiver (Age 30-32 BDE CDR Authority)
60
Applicant's Name Applicant's SSN
HQ, USACC, ATTN: RMID (Green to Gold) 204 1st Cavalry Regiment RoadFort Knox, KY 40121
COMMANDER(ROTC BDE Information)
ROTC BDE CDR NAME ROTC BDE CDR RANK DATE
Commander ROTC BDE CDR SIGNATURE
61
HQ, CADET COMMANDATTN: RMID (Green to Gold)204 1st Cavalry Regiment RoadFort Knox, KY 40121
COMMANDER(ROTC BDE Information)
Professor of Military Science(Program Information)
Applicant's Name Applicant's Rank/MOS Applicant's SSN
Dependency Waiver
1. Soldiers require a Dependency Waiver approved at ROTC BDE level for participation in the Green to GoldProgram when that Soldier: has more than 3 dependents, is the non-custodial parent, and/or is dual military withdependent(s) under 18 years of age
2. (Applicant's RANK Name) is/has (choose from one or more of the three options above) therefore is requestinga Dependency Waiver.
PMS RANK/NAME PMS SIGNATURE DATE
Sample Request for Dependency Waiver ( ROTC BDE CDR Authority)
62
Applicant's Name Applicant's SSN
HQ, USACC, ATTN: RMID (Green to Gold) 204 1st Cavalry Regiment RoadFort Knox, KY 40121
COMMANDER(ROTC BDE Information)
ROTC BDE CDR NAME ROTC BDE CDR RANK DATE
Commander ROTC BDE CDR SIGNATURE
63
HQ, CADET COMMANDATTN: RMID (Green to Gold)204 1st Cavalry Regiment RoadFort Knox, KY 40121
COMMANDER(ROTC BDE Information)
Professor of Military Science(Program Information)
Applicant's Name Applicant's Rank/MOS Applicant's SSN
Dependency Waiver
1. Soldiers required a Dependency Waiver approved at the USACC CG Level for participation in the Green to Goldprogram when that Soldier is: the sole parent of a dependent(s) under the age of 18 or has joint custody of a dependent(s)under the age of 18.
2. (Soldier's RANK Name) is/ has (choose from one of the 2 options above) and therefore requests a Dependency Waiver
PMS RANK/NAME PMS SIGNATURE DATE
Sample Request for Dependency Waiver (USACC CG Authority)
64
Applicant's Name Applicant's SSN
COMMANDER, USACC204 1st Cavalry Regiment RoadFort Knox, KY 40121
COMMANDER(ROTC BDE Information)
ROTC BDE CDR NAME ROTC BDE CDR RANK DATE
Commander ROTC BDE CDR SIGNATURE
HQ, USACC, ATTN: RMID (Green to Gold)204 1st Cavalry Regiment RoadFort Knox, KY 40121
COMMANDER, USACC204 1st Cavalry Regiment RoadFort Knox, KY 40121
USACC CG CDR NAME USACC CG CDR RANK
Commanding General USACC CG SIGNATURE
DATE
65
HQ, CADET COMMANDATTN: RMID (Green to Gold)204 1st Cavalry Regiment RoadFort Knox, KY 40121
COMMANDER(ROTC BDE Information)
Professor of Military Science(Program Information)
Applicant's Name Applicant's Rank/MOS Applicant's SSN
Active Federal Service (AFS)
1. Soldiers required an AFS Waiver approved at USACC CG Level for participation in the Green to Gold program whenthat Soldier will have over 10 years Active Federal Service at time of commissioning
2. (Soldier's RANK Name) will have________ years and________months of Active Federal Service at projected time ofcommission and therefore requests an AFS Waiver
PMS RANK/NAME PMS SIGNATURE DATE
Sample Request for AFS Waiver (USACC CG Authority)
66
Applicant's Name Applicant's SSN
COMMANDER, USACC204 1st Cavalry Regiment RoadFort Knox, KY 40121
COMMANDER(ROTC BDE Information)
ROTC BDE CDR NAME ROTC BDE CDR RANK DATE
Commander ROTC BDE CDR SIGNATURE
HQ, USACC, ATTN: RMID (Green to Gold)204 1st Cavalry Regiment RoadFort Knox, KY 40121
COMMANDER, USACC204 1st Cavalry Regiment RoadFort Knox, KY 40121
USACC CG CDR NAME USACC CG CDR RANK
Commanding General USACC CG SIGNATURE
DATE
67
