AMEDDApplicantWorksheet-July2012-3.doc

Persons completing this form should begin after

Info icon This preview shows pages 5–9. Sign up to view the full content.

View Full Document Right Arrow Icon
PERSONS COMPLETING THIS FORM SHOULD BEGIN AFTER CAREFULLY READING THE PRECEDING INSTRUCTIONS. I have read the instructions and I understand that if I withhold, misrepresent, or falsify information on this form, I am subject to the penalties for inaccurate or false statement (per U. S. Criminal Code, Title 18, section 1001), denial or revocation of a security clearance, and/or removal and debarment from Federal Service. No Yes 5
Image of page 5

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full Document Right Arrow Icon
6
Image of page 6
Applicant Information Social Security Number: Legal Last Name: Legal First Name: Legal Middle Name: Suffix (Jr., Sr., III, etc.): Physical Information Gender: Height: Weight: Eye Color: Hair Color: Last Menstrual Cycle Date (Females only): (dd-MMM-yyyy) Ethnicity Primary Race: Religion: Date and Place of Birth Date of Birth: (dd-MMM-yyyy) Age: City: State: County: Country: Citizenship [Mark ‘X’ to one that applies] U.S. Citizen at Birth, Native Born Federal States Micronesia or Virgin Island Non- Immigrant Foreign National U.S. Citizen at Birth, Born Abroad of U.S. Parents Immigrant Alien U.S. Naturalized Marshall Islands or Northern Mariana Islands U.S. Non-citizen National-American Samoa or Guam Non Immigrant Foreign National-Other Palau or U.S. Minor Outlying islands-Non- Immigrant Foreign National Home of Record address [HOR] Street: City: State: County: Zip Code: Country: Phone No.HOR: Current Address Street: City: State: County: Zip Code: Country: Where do you want Mail Sent? HOR or Current address: Contact Method Home: ( ) - Mobile: ( ) - Business: ( ) - Driver's License State: License No.: Exp. Date: (dd-MMM-yyyy) Marital Status (Mark ‘X’ to one that applies) Never Married Separated (Legally) Marriage Annulled Married Divorced Widowed # of Minor Dependents (Custody): Total # of Dependents: ADDITIONAL INFORMATION Foreign Education? Y/N: (If Yes, ECFMG, ECFVG, Fifth Pathway or Foreign Medical Graduate): Registered to Vote? Y/N: Prior Military Service? Y/N: 7
Image of page 7

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full Document Right Arrow Icon
PHYSICAL SCREENING Complete all questions. Additional information is required for ‘YES’ answers given, the question requiring additional information will be specified. Refer to the end of the Physical Screening section for further information needed for all other ‘YES’ answers provided. Y/N 1. Asthma, wheezing or inhaler use 2. Dislocated joint, including knee, hip, shoulder, elbow, ankle, or other joint 3. Epilepsy, fits, seizures, or convulsions 4. Sleepwalking 5. Recurrent neck or back pain 6. Rheumatic Fever 7. Foot pain 8. A swollen, painful, or dislocated joint or fluid in a joint (knee, shoulder, wrist, elbow, etc.) 9. Double vision 10. Periods of unconsciousness 11. Frequent or severe headaches causing loss of time from work or school or taking medication to prevent frequent or severe headaches 12. Wear contact lenses (If so, bring your contact lens kit and solution so you can remove your contact when your vision is tested at the MEPS; also, if you have a pair of eyeglasses, bring them with you no matter how old.) 13. Fainting spells or passing out 14. Head injury, including skull fracture, resulting in concussion, loss of consciousness, headaches, etc.
Image of page 8
Image of page 9
This is the end of the preview. Sign up to access the rest of the document.

{[ snackBarMessage ]}

What students are saying

  • Left Quote Icon

    As a current student on this bumpy collegiate pathway, I stumbled upon Course Hero, where I can find study resources for nearly all my courses, get online help from tutors 24/7, and even share my old projects, papers, and lecture notes with other students.

    Student Picture

    Kiran Temple University Fox School of Business ‘17, Course Hero Intern

  • Left Quote Icon

    I cannot even describe how much Course Hero helped me this summer. It’s truly become something I can always rely on and help me. In the end, I was not only able to survive summer classes, but I was able to thrive thanks to Course Hero.

    Student Picture

    Dana University of Pennsylvania ‘17, Course Hero Intern

  • Left Quote Icon

    The ability to access any university’s resources through Course Hero proved invaluable in my case. I was behind on Tulane coursework and actually used UCLA’s materials to help me move forward and get everything together on time.

    Student Picture

    Jill Tulane University ‘16, Course Hero Intern