ARIZONA AIR NATIONAL GUARD 161ST AIR REFUELING WING

MAY 2019

ARIZONA AIR NATIONAL GUARD

161

AIR REFUELING WING

UNDERGRADUATE PILOT TRAINING

APPLICATION WORKBOOK

161

Air Refueling Wing

3200 East Old Tower Rd.

Phoenix, AZ 85034-7263

Arizona Air National Guard

Headquarters 161

Air Refueling Wing

Phoenix Arizona

This application workbook contains information regarding your application for

Undergraduate Pilot Training with the Arizona Air National Guard in Phoenix. It

contains the eligibility and application requirements. It also includes all of the important

information that you will need to be considered for an interview.

The 161

Air Refueling Wing is located on the south side of Phoenix Sky Harbor

International Airport. Our primary mission is in-flight refueling. The unit is comprised

of one flying squadron, the 197

ARS flying the KC-135R aircraft. The unit employs

about 900 Traditional Guardsmen and about 300 full-time personnel.

We routinely fly 2-4 local sorties daily and 1-2 aircraft are deployed stateside or

overseas at any given time. In peacetime the 161

ARW is assigned to the State of

Arizona serving the Governor as our Commander in Chief. If the unit is federally

activated for any reason, our Commander in Chief is the President of the United States.

If selected for a pilot position, your obligation to the Air National Guard will be 10

years of service upon completion of training. You will be required to fly at least 4 sorties

per month, attend 1 drill weekend each month and be available for off base deployments

each quarter.

The Wing convenes a selection board once each year and will normally select two

primary candidates and two alternates. Once we receive your application package, it will

remain on file for consideration for one year. If we receive updated information such as

resume changes, the file will be kept for an additional year from when the update is

received. Selection as an alternate does not guarantee future selection for a training

slot. If you are not selected as a primary candidate, you will have to compete with

all other applicants again on future selection boards.

Questions regarding the application process may be directed to pilots in the

Operations Group.

ARIZONA AIR NATIONAL GUARD

UNDERGRADUATE PILOT TRAINING APPLICATION WORKBOOK

This workbook describes the application process for individuals interested in becoming a pilot in

the Arizona Air National Guard. Individuals must meet the requirements established by the United

States Air Force and those of the Arizona Air National Guard.

ELIGIBILITY

AGE: Candidates must be in pilot training prior to their 33

birthday. Age waiver will be evaluated on

a case by case basis up to 35 years of age.

EDUCATION: A bachelor's degree from an accredited four-year college or university is required. If

you are enrolled in your final semester at the time of the interview, your application will be

considered.

PCSM score: The Air Force has developed a composite scoring system to help select candidates who

have aptitude for completing the flight training programs. This system is called PCSM. The PCSM

score takes input from various factors, including education, flying hours, the AFOQT, and a hand-eye

coordination test called the TBAS. The PCSM and TBAS information can be found at the following

web site http://access.afpc.af.mil.

AFOQT: The Air Force Officers Qualification Test is mandatory prior to your application being

considered. This test takes approximately 4 hours and may be scheduled through the Luke AFB Base

Education Center. If you do not reside in Arizona, call a local Air Force recruiter to schedule this test.

Minimum Scores required are:

VERBAL: 15

QUANTITATIVE: 10

PILOT: 25

NAVIGATOR: 10

TOTAL: 50 (the minimum required score when adding pilot and navigator totals)

These scores are minimum scores required to pass the AFOQT test. The scores of this test are a factor

in the interview process. It is strongly recommended that you prepare for this test. You will find study

material at most bookstores and libraries that carry SAT preparatory material.

TBAS TESTING: The Basic Attribute Test is an eye-hand coordination test usually done at an Active

Duty Air Force Base or a ROTC location. The TBAS test is mandatory prior to your application being

considered. Your AFOQT test needs to be completed two weeks prior to taking the TBAS test.

These tests (AFOQT, and TBAS) can be self-scheduled in your local area. In the Phoenix area,

contact the testing center at Luke AFB, DSN 896-2253, commercial 623-856-2253, email

[email protected]. The tests are administered at Luke AFB Base Education Center, DSN 896-

7722 or commercial 623-856-7722. If you do not reside in Arizona, call a local Air Force recruiter or

Base Education Center to schedule these tests.

PHYSICAL: All pilot applicants must be in excellent physical and psychological health. You must

include in your application the Medical Prescreening Form, which is provided in this workbook.

Minimum vision requirements are 20/70 corrected to 20/20 with no exception. You must have full

hearing in both ears and meet height and weight standards.

MORAL STANDARD: This section involves criminal history. A local application is included in this

workbook. Any law violations, including juvenile offenses and traffic violations must be documented on

this application. Law violations do not necessarily disqualify an individual, but non-disclosure of any

offense is disqualifying. If selected, a federal background check will be initiated as part of the security

clearance requirement.

APPLICATION PACKAGE: This workbook includes the items that are mandatory in your application

package. A package will only be considered for an interview if it is complete. For any required item

that is not included, you must attach a letter of explanation. All packages will be kept on file for 1 year.

Important dates:

1) 15 May - Deadline for Application and

2) 17 May - Interview Announcements

3) 01 June - Meet & Greet

4) 02 June - Interview Board

PILOT APPLICATION PACKAGE REQUIREMENTS

MANDATORY

1. Cover Letter (Addressed to: 161ARW Undergraduate Pilot Training Board)

2. Resume

3. AFOQT Test Results

4. PCSM results (http://access.afpc.af.mil) This is a combined score of AFOQT, TBAS and Flying

hours.

5. College Transcripts (Official Transcripts will be required upon request)

6. Local Application (Contained in this workbook)

7. Medical 2807 Form (Contained in this workbook)

8. 3 Letters of Recommendation

9. If you are prior Military Service, you must include your discharge paperwork and/or most

recent evaluation report.

10. If you have flight experience, a copy of your licenses and the last page of your logbook.

NOTE: It is not mandatory, but it is desirable to have at least a civilian private pilot license. Please

provide copies of any pertinent flying qualifications that you have.

The importance of a completed package cannot be overstated, however, do not include

additional extraneous information. The Selection Board will only review the items listed above during

the selection process. Your completed package will be graded for quality and presentation. Mail or

hand-carry a hard copy of your complete package to the 161

ARW / Operations at the following

address:

161

Air Refueling Wing

Operations Group Attn: Capt KJ Irwin,

3200 East Old Tower Rd.

Phoenix, AZ 85034-7263

The most important thing is to ensure we received your application. It is your responsibility to

ensure that our office received your applications. If you give us your e-mail we will send you a

message indicating that we have received your application and are reviewing it.

As you understand, the UPT selection process is competitive and an application itself

does not guarantee an interview.

We realize the application process is time consuming, and

we do our best to honor highly qualified candidates with interviews. Good luck and we wish

success for all applicants.

For questions call 602-302-9030, (DSN) 853-9030, or e-mail to: [email protected]

Questions can be addressed to:

Captain Kenneth “KJ” Irwin

INTERVIEWS

Interviews will be conducted when allocations for Pilot Training class dates are received by the 161

ARW. Normally, we will interview 10-12 candidates per class slot. Generally the 161

is allocated 1 to

4 class slots each fiscal year. The interview process is as follows:

 All Pilot Packages will be read and considered by a selection team comprised of at least 5 pilots.

This team will submit 10-12 packages to the Operations Group Commander with requests for

interviews.

 The Operations Group Commander will convene a board of officers to review the applications,

records, and interview each applicant. The board will be charged to evaluate each applicant’s

suitability to be commissioned as an officer in the United States Air Force and Air National Guard.

 Applicants will be rated by point values based on military experience, aviation experience,

professionalism, local ties, military scores, college background, application quality, communication

skills and your answers to a number of questions. The board will also be directed to eliminate any

applicant who they conclude to be not suited for commissioning for flight training.

SELECTION PROCESS

The applicants with the highest point ratings will have their applications forwarded through

command channels for review and approval. Final approval rests with the US Air Force. To follow is

the selection process:

IF SELECTED AS A PILOT CANDIDATE OR ALTERNATE

 The applicant will be required to take and pass an Air Force Flying Physical administered at Wright

Patterson AFB, OH

 Applicant will be required to complete and submit a Top Secret Security Clearance Survey.

 Non-Prior Service candidates will be enlisted into the unit until graduation from Total Force Officer

Training (TFOT) as a Second Lieutenant.

 The applicant with the highest point rating will receive the first school position allocated to the unit.

The unit may also be offered an additional class assignment on short notice due to cancellations by

other units.

Please note: The amount of coordination and paperwork required for a candidate can be very

demanding. You must be prepared for no-notice trips to the 161

to sign paperwork, provide copies of

documents, testing etc. Generally the approval process takes 6-9 months, possibly longer. The approval

process will go through the chain of command starting with the 161

Air Refueling Wing followed by

the AZ State Headquarters, Air National Guard Headquarters, and United States Air Force Headquarters.

Patience and flexibility will come in handy. All trips to the 161

ARW to complete the

application/selection process will be at the candidate's expense.

PILOT TRAINING PROGRAM

If you are selected as a Pilot Candidate, you will be required to complete the mandatory initial training

that will require approximately 1 to 2 years to complete. Acceptance of this commitment should not be

taken lightly. Successful completion of this training program requires dedication, long hours and strong

support from your family. Your family should be fully aware of and prepared for this demanding period.

Feel free to make an appointment for you and your spouse (if applicable) to talk with someone at the

unit about the pilot training program. The following is a breakdown of this training.

IFT: Initial Flight Training is required if you do not have your Private Pilots License. You will be

required to complete an Air Force flight screening course in Pueblo, CO before going to AMS.

4 Weeks

Medical Flight Screening: This is a physical evaluation at Wright-Patterson Air Force Base.

4 Days

TFOT (Total Force Officer Training): Officer Training School.

8 Weeks

UPT (Undergraduate Pilot Training): Initial Flight School including academic preparation and training

in the T-6 and T-1 aircraft.

52 Weeks

Water Survival Training: Fairchild Air Force Base, Spokane, Washington.

5 Days

Combat Survival Training: Fairchild Air Force Base, Spokane, Washington.

17 Days

Pilot Initial Qualification Training: KC-135 CCTS, Altus Air Force Base, Altus, Oklahoma

~20 Weeks

NOTES

All of the above training will be paid training. Families are not permitted to accompany you to TFOT.

Therefore, any family members that join you will do so at their own expense.

Training is conducted in several locations throughout the nation, and is subject to change. You will be

informed of locations should you be selected.

Completion of the above training program currently carries a 10-year obligation with the Air National

Guard.

It is highly preferred that you reside or plan to live within 50-100 miles of the base in Phoenix upon

returning from training.

161

AIR REFUELING WING / AZ AIR NATIONAL GUARD

LOCAL APPLICATION FOR PILOT

SECTION 1 PERSONAL INFORMATION

Name _________________________________________________________________ SSAN ___________________________________

Address ________________________________________________________________________________________________________

Home Phone ___________________________ Work Phone ____________________________ E:Mail __________________________

Age ________ Birth Date ________________________________________ Marital Status ______________

SECTION 2 EDUCATION

High School Graduate? YES NO College Graduate? YES NO Date of College Graduation _______________________

Name of College from which you graduated or are enrolled ____________________________________________________________

Major ______________________________________________________________________ Grade Point Average ________________

Type of Degree Received or pursuing _______________________________________________________________________________

SECTION 3 MILITARY BACKGROUND (If you have never served in the military please skip to next section)

Branch, Unit and Location of current assignment or most recent assignment ______________________________________________

________________________________________________________________________________________________________________

Job Title ____________________________________ Rank ___________________ Security Clearance Level ____________________

Date of Enlistment/ Appointment ____________________________________ Date of Separation _____________________________

Have you ever attended Flight Screening, Officer Training or Undergraduate Pilot Training for any branch of the Service and if so,

did you graduate from the program? Explain ________________________________________________________________________

________________________________________________________________________________________________________________

SECTION 4 FLIGHT BACKGROUND (If you have no flight experience, please skip to the next section)

Do you have a Private License YES NO Total Flying Hours Student _______________________

Do you have a Commercial Pilot License YES NO Total Flying Hours PIC __________________________

Do you have an Instrument Rating YES NO Total Hours ____________________________________

Type of Aircraft flown as student or PIC ____________________________________________________________________________

________________________________________________________________________________________________________________

SECTION 5 PRIOR EMPLOYMENT (3 most recent employers)

1. Company_________________________ Position_________________ Address _____________________________________________

Phone_______________ Dates Employed ________________ Supervisor Name/Phone Number__________________________________

Reason for Leaving __________________________________________________________________________May We Contact YES NO

2. Company_________________________ Position_________________ Address _____________________________________________

Phone _______________ Dates Employed ________________ Supervisor Name/Phone Number_________________________________

Reason for Leaving __________________________________________________________________________May We Contact YES NO

3. Company_________________________ Position_________________ Address _____________________________________________

Phone _______________ Dates Employed ________________ Supervisor Name/Phone Number_________________________________

Reason for Leaving __________________________________________________________________________May We Contact YES NO

SECTION 6 REFERENCES (Need not to be the same as the letters of recommendation)

1. Name_______________________________ Phone Number _____________________________ May We Contact YES NO

How do you know this person?________________________________________________________________________________________

2. Name_______________________________ Phone Number _____________________________ May We Contact YES NO

How do you know this person?________________________________________________________________________________________

3. Name_______________________________ Phone Number _____________________________ May We Contact YES NO

How do you know this person?________________________________________________________________________________________

4. Name_______________________________ Phone Number _____________________________ May We Contact YES NO

How do you know this person?________________________________________________________________________________________

5. Name_______________________________ Phone Number _____________________________ May We Contact YES NO

How do you know this person?________________________________________________________________________________________

APPLICATION CONTINUED

Are you a conscientious objector? YES NO (A conscientious objector is defined as one who refuses to serve in the Armed Forces or

bear arms on the grounds of moral or religious principals.)

Are you a sole survivor? YES NO (A sole surviving son or daughter is the only remaining son or daughter in a family where a parent

or one or more sons or daughters was (a) killed in action or died in the line of duty while serving in the Armed Forces (b) is in a

captured or missing-in-action status or (c) is permanently 100% disabled, physically or mentally employed due to such disability.

NOTE: Members may acquire and obtain sole surviving son or daughter status even if there are no other living family members. It

does not depend on the existence of a family unit. A sole surviving son may have living sisters and a sole surviving daughter may have

living brothers.)

Are you a United States Citizen? YES NO If no please explain ___________________________________________________________

Are you currently enrolled in an advanced course or a scholarship program in ROTC? YES NO

Have you engaged in any act or acts designed to destroy or weaken the United States? YES NO

Are you under the influence of drugs or alcohol? YES NO

Are you an alcoholic? YES NO

If you are an alcoholic, have you completed a rehabilitation program? YES NO

Have you ever completed a drug rehabilitation program? YES NO

Do you have a history of mental illness? YES NO

Have you ever been charged, arrested, cited or held by any law enforcement agency to include juvenile offenses or traffic violations?

YES NO If yes, please provide the nature of EACH offense, date of the incident, fines or sentencing and the final disposition.

_________________________________________________________________________________________________________________

Have you ever used, possessed, sold or transported any illegal drugs to include marijuana? YES NO If yes, please describe each drug

used and the last time it was used. ____________________________________________________________________________________

_________________________________________________________________________________________________________________

In connection with my Application for Appointment in the Arizona Air National Guard, I certify that the proceeding is a true and

correct statement of eligibility. I understand that any information purposely left out of my application may render me ineligible for a

commission with the Arizona Air National Guard.

_____________________________________________________________________________ ___________________________________

(Printed Full Name) (Date)

_________________________________________________________________________

(Signature)

INSTRUCTIONS FOR COMPLETING DD FORM 2807-2,

ACCESSIONS MEDICAL PRESCREEN REPORT

1. This form is to be completed by each individual who requires medical processing in accordance with Department of Defense Instruction (DODI)

6130.03, "Physical Standards for Appointment, Enlistment, or Induction" and DODI 1304.02, "Accession Processing Data Collection Forms." This

form must be completed by the applicant with the assistance of the recruiter, parent(s), or guardian, as needed.

6. MEPS Chief Medical Officers (CMOs) may locally modify the above instructions and instruct recruiters on what supporting medical documents they

require to complete the DD Form 2807-2 medical prescreen review, if doing so enhances the efficiency of medical processing and is consistent with

DODI 6130.03 and USMEPCOM guidance.

7. If all attempts to obtain required substantiating and supporting medical documents fail, the recruiter must contact the MEPS medical department for

guidance prior to submitting an incomplete medical prescreen packet.

2. Replaces the existing medical prescreen form (DD Form 2807-2, AUG 2011). Additional questions have been added to improve its usefulness to

the accessions medical pre-screening process. The questions are intended to provide the U.S. Military Entrance Processing Command (USMEPCOM)

with health history information necessary to identify conditions commonly related to medical causes for separation during basic and follow-on training

(per P.L. 105-85, Div. A, Title V, S 532).

3. Use of medical history information facilitates efficient, timely, and accurate medical processing of individuals applying for Service in the United

States Armed Forces or United States Coast Guard. Positive responses do not automatically result in disqualification but are necessary to prompt

further explanation that will be used to determine medical qualification.Medical history information assists USMEPCOM medical personnel in the

medical prescreening of applicants. Accurate responses to all questions are critical and all positive responses must be fully explained. Applicant

responses to questions may be verified using electronically obtained medical history by the USMEPCOM. Medical history information will be used by

the Department of Defense for continuity of care purposes if and when an applicant accesses into the Armed Forces or Coast Guard. Supporting

medical information in the form of historical medical records may also be attached to the Service member's medical record. Medical history

information collected by the USMEPCOM during accession medical processing will serve as the foundation for a Service member's lifecycle medical

treatment record.

4. The completed DD Form 2807-2 along with all substantiating and supporting medical documents must be delivered to USMEPCOM for review prior

to scheduling the applicant for medical examination. All documents must be submitted for review in accordance with standards below. After review,

the MEPS will notify the Recruiting Service of the applicant's status.

- 1 processing day prior for applicants with no positive medical history (all items marked "NO" with the exception of items 9 (glasses/contacts), 11

(defective color vision), and 20 (braces) which can be "YES").

- 2 processing days prior; for applicants with ANY positive medical history (other than those noted above) and 5 OR LESS single-sided pages of

supporting medical documents.

- 3 processing days prior; for applicants with ANY positive medical history (other than those noted above) and MORE THAN 5 single-sided pages

of supporting medical documents.

Secure electronic submission is preferable; if not feasible bring/mail to the nearest Military Entrance Processing Station (MEPS) which can be found at

http://www.mepcom.army.mil/battalions/index.html

. All supporting medical documentation must be present with the DD Form 2807-2 to meet the

above timeframes for review. After review by a USMEPCOM provider, appropriate processing notification will be made.

5. If an applicant has been seen by any health care provider (HCP) and/or has been hospitalized for any reason, medical records/documentation must

be obtained and submitted along with a medical release to USMEPCOM. Provide all medical documents via secure electronic submission (if possible) to

the nearest MEPS. If hand-carried or mailed ensure they are sealed in an envelope marked: "CONFIDENTIAL: MEPS MEDICAL DEPARTMENT".

a. If the applicant was evaluated and/or treated on an out-patient basis, obtain a copy of actual treatment records of the private medical doctor/

healthcare provider including:

(1) office or clinic assessment and progress notes, including the initial assessment documents, subsequent evaluation and treatment documents, and

record of date when released from care to full, unrestricted activity;

(2) emergency room (ER) report(s);

(3) study reports (e.g. x-ray, magnetic resonance imaging (MRI), Computerized Tomography (CT), etc.);

(4) procedure reports (e.g., arthroscopy, electroencephalogram (EEG; brain wave test), echocardiogram (ultrasound of the heart), etc.);

(5) pathology reports (e.g., tissue specimens sent to lab for microscopic diagnosis, abnormal PAP smear cytology, etc.);

(6) specialty consultation records (e.g., neurologist, cardiologist, OB/GYN, gastroenterologist, orthopedic surgeon, pulmonologist, allergist, etc.).

b. If the applicant was hospitalized, obtain a copy of the inpatient hospital record, to include (if any): ER report, admission history and physical,

study reports, procedure reports, operative report (example: surgery to bone or joint), pathology report, specialty consultation reports, and discharge

summary.

c. If an applicant has been diagnosed or treated for any attention disorder (Attention Deficit Disorder (ADD), Attention Deficit Hyperactivity

Disorder (ADHD), etc.), academic skills or perceptual defect, or had an Individualized Education Plan or 504 Plan, call/contact the MEPS medical

department for additional instructions.

d. Obtain any and all documents relating to any evaluation, treatment or consultation with a psychiatrist, psychologist counselor, or therapist, on an

inpatient or out-patient basis for any reason, including but not limited to counseling or treatment for adjustment or mood disorder, family or marriage

problems, depression, treatment or rehabilitation for alcohol, drug, or substance abuse.

DD FORM 2807-2, MAR 2015

PREVIOUS EDITION IS OBSOLETE.

Page 1 of 7 Pages

Adobe Designer 9.0

ACCESSIONS MEDICAL PRESCREEN REPORT

OMB No. 0704-0413

OMB approval expires

Oct 31, 2017

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

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS.

PRIVACY ACT STATEMENT

AUTHORITY:

PRINCIPAL PURPOSE(S):

10 U.S.C. 504, 505, 507, 532, 978, 1201, 1202, and 4346; and E.O. 9397 (SSN).

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):

DoD Blanket Routine Uses found at

http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx

apply to this use of this

data.

DISCLOSURE:

Voluntary, however, failure by an applicant to provide the information may result in delay or possible rejection of the individual's application

status.

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

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. SOCIAL SECURITY NUMBER

1. LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)

5. HEIGHT

(inches)

9. DATE

(YYYYMMDD)

12. USUAL OCCUPATION

8. SERVICE AND COMPONENT

(X as applicable)

10. PURPOSE OF EXAMINATION

(X as applicable)

11. POSITION

(If a current Federal Employee)

(Job Title, Grade, Component)

7. MAX WEIGHT

(lbs.)

6. WEIGHT

(lbs.)

2. AGE

SECTION I - APPLICANT

SECTION II - MEDICAL HISTORY.

Initial each item "Yes" or "No". All "Yes" items must be fully explained in Section III (Pages 4 and 5).

Army

Enlistment

U.S. Service Academy

(Specify)

1. Double vision

8. Any other eye condition, injury or surgery

10. Loss of vision in either eye

11. Color vision deficiency or color blindness

7. Strabismus or "lazy eye" or any surgery to correct these

6. Glaucoma

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

USMC

Regular

CURRENTLY HAVE OR ANY HISTORY OF:

EYES

22. Asthma

27. Used inhaler(s) or steroids for breathing problem(s)

30. History of chest, chest wall, or breast surgery

29. Collapsed lung or other lung condition

28. Chronic cough or frequent coughing at night

26. Other breathing problems worsened by exercise, weather,

pollens, etc.

25. Bronchitis

24. Shortness of breath

23. Wheezing

LUNGS, CHEST WALL, PLEURA, AND MEDIASTINUM

21. Tooth or gum problems (other than cavities)

12. Perforated ear drum or tubes in ear drum(s)

14. Loss of balance or vertigo

13. Ear surgery, to include mastoidectomy or repair of

perforated ear drum

EARS

31. Heart murmur, valve problem or mitral valve prolapse

36. Any other heart problems

35. An abnormal electrocardiogram (EKG)

34. Pain or pressure in the chest

33. Heart surgery

32. Palpitation, pounding heart or abnormal heartbeat

HEART

37. Stomach, esophageal or intestinal ulcer

45. Rectal disease, hemorrhoids, or blood from the rectum

47. Bariatric surgery (weight loss surgery)

46. Hemorrhoid surgery

42. Rupture/hernia

44. Chronic or recurrent intestinal problem of the small or large

bowel such as Irritable Bowel Syndrome, Crohn's disease,

Ulcerative Colitis, or Celiac disease

43. Surgery to remove or repair a portion of the intestine or

spleen (other than the appendix)

41. Jaundice (except neonatal) or hepatitis (liver disease)

40. Gall bladder trouble or gallstones

39. Frequent indigestion or heartburn

38. Difficulty swallowing

ABDOMINAL ORGANS AND GASTROINTESTINAL SYSTEM

15. Hearing loss or wear a hearing aid

HEARING

16. Ear, nose, or throat trouble including tonsillectomy

19. Any surgery of your face, mandible or jaw

18. Absence of, or disturbance of sense of smell

17. Chronic sinus infections or recurrent nose bleeds

NOSE, SINUSES, MOUTH, AND LARYNX

9. Worn/wear contact lenses or glasses (Bring your contact

lens kit and solution so you can remove contacts during

vision testing, or for best results remove 72 hours prior.

Bring your eyeglasses no matter how old they are.)

VISION

20.

Do you wear dental braces or plan to wear braces? (If so, your

orthodontist must submit a letter stating that active orthodontic

treatment will be completed prior to active duty date: release form/

sample format can be found in the Recruiter's Medical Guide.)

DENTAL

YES

CURRENTLY HAVE OR ANY HISTORY OF:

YES

Page 2 of 7 Pages

DD FORM 2807-2, MAR 2015

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, Executive Services Directorate, Directives Division, 4800 Mark Center Drive, Alexandria, VA 22350-3100

(0704-0413). 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.

Commission

Retention

ROTC Scholarship

Other

Navy

USAF

USCG

Other:

Reserve Component

National Guard

3. DATE OF BIRTH

(YYYYMMDD)

1996111

LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)

SECTION II - MEDICAL HISTORY

(Continued)

. Initial each item "Yes" or "No". All "Yes" items must be fully explained in Section III.

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 (after childhood)

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

ENDOCRINE AND METABOLIC

67. Recurrent back pain or back problem

71. Abnormal curvature of your spine (any part)

70. Back or neck surgery

69. Recurrent 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

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

86. Pain or swelling at the site of an old fracture

85. Plate(s), screw(s), rod(s) or pin(s) in any bone

84. Surgery on any joint/bone (including arthroscopy)

83. Any swollen joint(s)

82. Arthritis, rheumatism, 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

LEARNING, PSYCHIATRIC, AND BEHAVIORAL

131. Evaluated or treated for Attention Deficit Disorder (ADD) or

Attention Deficit Hyperactivity Disorder (ADHD)

133. Diagnosed with a learning disorder, to include dyslexia

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 request

sealed medical supporting documents from health care pro-

viders marked "CONFIDENTIAL: MEPS MEDICAL DEPART-

MENT" and submit directly to MEPS medical personnel.)

134. Received counseling of any type

132. Taken (or taking) medication, drugs, or any substance to

improve attention, behavior, or physical performance

SLEEP DISORDERS

89. High or low blood pressure

90. Raynaud's phenomenon or disease

92. Pulmonary embolism (blood clot in lung)

91. Deep Vein Thrombosis (blood clot; leg or elsewhere)

VASCULAR

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

93. Acne or psoriasis

96. Large or painful scars

97. Any other skin problems

95. Atopic dermatitis

94. Eczema

SKIN AND CELLULAR

98. Anemia

99. Blood clots requiring blood thinner medicine

101. Prolonged bleeding (after an injury or tooth extraction)

102. Any other blood or circulation problems

100. Absence or removal of the spleen

BLOOD AND BLOOD FORMING TISSUES

103. Adverse reaction to medication

105. Allergy to common foods (milk, eggs, fish, meat, etc.)

111. Car, train, sea, or air sickness

110. Disorder(s) of your immune system (including HIV)

109. Malaria

114. Diabetes or told that you should be tested for diabetes

113. High or low blood sugar

112. Thyroid trouble or goiter

NEUROLOGIC

117. Taking medication to prevent headaches

116. Frequent or severe headaches, including migraines

115. Cerebrovascular incident (stroke)

126. Dizziness or fainting spells

127. Any other neurologic problems

125. Seizures, convulsions, epilepsy or fits

124. Meningitis, encephalitis, or other neurological problems

130. Sleep apnea or severe snoring

129. Frequent trouble sleeping

128. Sleepwalking or narcolepsy

123. Paralysis

122. Loss of memory or amnesia, or neurological symptoms

121. A period of unconsciousness or concussion

120. A head injury, memory loss, or amnesia

119. A skull fracture

118. Lost time from work or school due to frequent or severe

headaches

108. Positive test for tuberculosis (PPD or blood test)

107. Tuberculosis or lived with someone who had tuberculosis

106. Allergy to wool, latex, or other material

104. Adverse reaction to serum, insect stings, or tree nuts

SYSTEMIC

YES

CURRENTLY HAVE OR ANY HISTORY OF:

YES

Page 3 of 7 Pages

DD FORM 2807-2, MAR 2015

(describe reaction in Section III)

SOCIAL SECURITY NUMBER

(Last 4)

123

LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)

SECTION II - MEDICAL HISTORY

(Continued)

. Initial each item "Yes" or "No". All "Yes" items must be fully explained in Section III.

SECTION III - 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.

CURRENTLY HAVE OR ANY HISTORY OF:

YES

CURRENTLY HAVE OR ANY HISTORY OF:

YES

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

alcohol abuse, dependence, or addiction

149. Any other learning, psychiatric, or behavioral problems

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

150. Tumor, growth, cyst, or cancer of any type

TUMORS AND MALIGNANCIES

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 counter

medications (OTCs), vitamin, herbal, or nutritional

supplements (If "yes", list all in Section III.)

154. Any recent unexplained gain or loss of weight

155. Artificial or replacement body part (eye, bone, palate, hip,

knee, joint, leg, arm, etc.)

156.

Have you ever had any illness or injury other than those

already noted? (If "yes", specify when, where and give

details in Section III.)

SUPPLEMENTAL QUESTIONS

157. Have you ever been treated in an Emergency Room?

(If "yes", explain in Section III.)

160. Have you ever been rejected for military Service for any

reason? (If "yes", give date and reason in Section III.)

161.

162. Have you ever been refused employment or been unable to

hold a job or stay in school because of any of the following:

(If "yes", answer a - d below and give reasons in Section III.)

163. Applied for and/or received disability evaluation and/or

compensation for an injury or other medical conditions

(If "yes", provide details in Section III.)

164. Have you ever been denied life insurance? (If "yes",

provide reason(s) in Section III.)

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 III.)

158.

Have you ever been a patient in any type of hospital (including

being kept overnight)? (If "yes", specify when, where, why, and

name of doctor and complete address of hospital in Section III.)

SUPPLEMENTAL QUESTIONS

(Continued)

Page 4 of 7 Pages

DD FORM 2807-2, MAR 2015

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

Have you ever been discharged from the military Service for any

reason? (If "yes", give date, reason, and type of discharge, whether

honorable, other than honorable, for unfitness or unsuitability in

Section III.)

SOCIAL SECURITY NUMBER

(Last 4)

124

Birth Sex: Preferred Gender:

SOCIAL SECURITY NUMBER

(Last 4)

LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)

SECTION III - APPLICANT COMMENTS

(Continued)

SECTION IV - 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 AreaCode)

b. ADDRESS

(Include ZIP Code)

a. NAME(S)

1. CURRENT PRIMARY CARE PHYSICIAN(S)/PRACTITIONER(S) AND/OR CLINIC(S)

c. TELEPHONE

(Include AreaCode)

b. ADDRESS

(Include ZIP Code)

a. NAME(S)

2. PREVIOUS PRIMARY CARE PHYSICIAN(S)/PRACTITIONER(S) AND/OR CLINIC(S)

c. TELEPHONE

(Include AreaCode)

b. ADDRESS

(Include ZIP Code)

a. NAME(S)

3. CURRENT INSURANCE AND/OR PHARMACY BENEFIT MANAGER(S)

c. TELEPHONE

(Include AreaCode)

b. ADDRESS

(Include ZIP Code)

a. NAME(S)

4. PREVIOUS INSURANCE AND/OR PHARMACY BENEFIT MANAGER(S)

Page 5 of 7 Pages

DD FORM 2807-2, MAR 2015

NONE

SOCIAL SECURITY NUMBER

(Last 4)

LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)

SECTION V - APPLICANT VALIDATION, AUTHORIZATION AND SIGNATURE

STOP AND READ: THE FOLLOWING STATEMENTS APPLY TO SIGNATURES IN SECTION V (BELOW)

I (we) , the undersigned:

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.

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 that I will 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 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

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).

Understand that I must provide required documentation regarding my health history which, upon my accession, will become

part of my Service member lifecycle medical treatment record.

Authorize the Department of Defense (DoD) to request holders of medical/behavioral health data (including but not limited to

healthcare providers, clinics, hospitals, insurance companies, pharmacy benefit managers, pharmacies, health information

exchanges, and federal and state agencies) to release to the DoD medical authority a complete transcript of my health data for

purposes of processing my application for Military Service. I also authorize holders of my health data to report to the DoD

whether any data they hold or have held about me has been amended or restricted. 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.

Authorize release of records and information relating to grades, performance, individual education plans, and disciplinary

proceedings. Under the Family Educational Rights and Privacy Act (FERPA) USMEPCOM is authorized to receive all my

education/disciplinary records for evaluation of my acceptability for Service in the Armed Forces.

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.

Understand this authorization will expire two years from the date of the signature below or sooner if written request is

received by USMEPCOM 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.

c. DATE SIGNED

(YYYYMMDD)

b. SIGNATURE

a. NAME

(Last, First, Middle Initial)

2. PARENT OR GUARDIAN SIGNATURE IS MANDATORY FOR MINOR APPLICANT,

SIGNATURE IS OPTIONAL IF APPLICANT IS OF AGE

b. DATE SIGNED

(YYYYMMDD)

a. SIGNATURE

1. APPLICANT

d. DATE SIGNED

(YYYYMMDD)

c. SIGNATURE

b. RECRUITER

IDENTIFICATION NUMBER

a. NAME

(Last, First, Middle Initial)

3. RECRUITING REPRESENTATIVE:

(If a representative was used)

I certify all information is complete and true to the best of my knowledge.

Page 6 of 7 Pages

DD FORM 2807-2, MAR 2015

20180702

Garcia, Matthew B.

20180702

AZ161ROSWW

SOCIAL SECURITY NUMBER

(Last 4)

LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)

SECTION VI - 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:

SECTION VII - MEDICAL PROVIDER'S PRESCREEN DETERMINATION BASED ON AVAILABLE INFORMATION:

1.a. DATE

(YYYYMMDD)

h. DATE

(YYYYMMDD)

b. MEDICAL PROCESSING STATUS

ON EXAM:

i. PROVIDER INITIALS

d. *AE

g. *OE

f. *ME

e. *RE

c. NPS

b. PSN INCOM

a. PSN COMP

PULHES

SMWRA INPUT

CONDITION

ICD

METR

PNJ

PRW

d. PROVIDER

INITIALS

c. IF NOT WITHIN STANDARDS:

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.

KEY:

PSN = Prescreen; COMP = Complete; INCOM = Incomplete; NPS = Not Prescreened; AE = Applicant Error; RE = Recruiter Error; ME = MEPS Error;

OE = Other Source of Error.

2. *FOR MEPS USE ONLY:

3. AUTHORIZING MEDICAL PROVIDER

4. NUMBER OF

ADDITIONAL

SHEETS

SUBMITTED

c. DATE SIGNED

(YYYYMMDD)

b. SIGNATURE

a. NAME

(Last, First, Middle Initial)

Page 7 of 7 Pages

DD FORM 2807-2, MAR 2015

CONTINUATION PAGE

DD Form 2807-2