Form NAVCRUIT 1131-238 NAVCRUIT 1131-238 Application for Commission in the US Navy/US Navy Reserv

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PRIVACY ACT STATEMENT
AUTHORITY Title 10 United States Code, Sections 591 , 600, 2107,2122, and 6019 which prescribes qualifications for appointment in the Armed Forces of the United
States, information regarding your educational background, involvement with law enforcement agencies, juvenile, traffic, criminal, or other, including foreign countries , drug
usage, physical problems or prior processing, whether for U.S. Navy or branches of the services not withstanding. Executive Order 9397 authorizes the solicitation of the
Social Security Number (SSN).
PRINCIPAL PURPOSES: To determine the applicant's eligibility for appointment into the United States Navy. The information provided is FOR OFFICIAL USE ONLY and will
become a permanent part of your service record and will be maintained and used in strict confidence in accordance with Federal Law and Regulations. The Social Security
Number will be used to verify, identify and locate existing records.
ROUTINE USES: To obtain background information provided by the applicant and by a Selection Board to determine applicant's qualifications for commission.
DISCLOSURE: Disclosure is voluntary, however, failure to provide the requested information as well as the social security number may result in denial of appointment into
the United States Navy. If, after you enlist, it is found that you concealed a record , you may be discharged from the U. S. Navy as a fraudulent apPOintment and may be
subject to a fine and/or imprisonment.

APPLICATION PROCESSING AND SUMMARY RECORD
(YOU MUST ENABLE JAVA TO COMPLETE THIS FORM)
1. PERSONNEL INFORMATION
a. NAVCRUITDIST

f. SSN

rAge

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II g.

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10. Race

In . Body Fat

Choice
v. Program
w. NOBC/SSP

Ethnic

I q. Citizenship

e. SuffiX/Maiden

d. Middle Name or NMN

c. First Name

Place of Birth (City/State or Foreign Country) I h. DOB

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m. WI.

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I b. Last Name

I j . Age waiver req . I k. Sex

r. If dual, list country I s. Enlisted It. SKED to ship to RTC IU ' Interview Scores

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Ip

1

II. HI.

Choice 4

Choice 3

Choice 2

Choice

5

I I I I I I I I I I I I I II I I I I I II I I I I I II I I I I I I
I I I I I I II I I I I I II I ' I I I I II I I I I I II I I I I I I

2, MILITARY SERVICE
a. Current MIL Status

Branch

I c.

Ib

Paygrade I d. Prior Service

3. EDUCATIONAL STATUS - Most Current

1

a. Name of Educational Institution

4. TESTING
a. AQR lb. PFAR

I c. FOFAR

b . Major (Continue in block

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d . OAR Ie. Other Test:

-*•••

5. COMMISSIONING DATA
a . Commissioning Program

Test Date

15)1

c. Edu/Grad. Level

1

d. GPA

I g. Avail date for OCS/ODS/SELRES.

,
Ie. Grad Date

I h. Recon

NRC USE ONLy·········
Grade

Ib

I f. Scores:

I f . Paygrade

I e. Branch

l

c , Date of Rank I d . Desig'l e . Type

I f. Scroll Sub Date:

I g.

Scroll App

pate:

h. Original Source Code:
i. Current Source Code:
I

j . Restrictions:

I k. Restrictions :

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Restri~tions:

I m . Restrictions: I

n. Restrictions:

I o. Restrictions: I

BUPERS USE ONLY

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OSDAPP

Remarks

PC :

Authority:

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SECNAVAPP

NAVCRUIT 11311238 (REV 7-2010(2))

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Senate Confirmed

Date Approved

Null & Void Date

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6. COMPENSATION/ALLOWANCES AND PENSIONS
DUAL COMPENSATION STATEMENT AND WAIVER OF CLAIM
I understand that if I execute an enlistment into an Officer Candidate program or receive a commission in the U.S. Navy or Navy Reserve, I may not draw any of the
compensation prescribed for active duty, active duty for training, or inactive duty training for the same period that I am drawing or claiming a pensionl retirement! retainer pay,
or disability compensation from the U.S. Government by virtue of prior military service. Therefore, I hereby voluntarily agree to waive the pensionl retirement! retainer payor
disability compensation I am receiving effective at the time I begin receiving any compensation for active duty, active duty for training, or inactive duty training.
NO IYesl

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Applicant's Initials:
Enter additional remarks in block 15
a. Have you ever claimed or been granted a pension! disability allowance! disability compensation! or retirement pay from the U.S. Govt?
b. Are you presently receiving such compensation? If Yes , explain in the Remarks section and initial statement in block 6.

7. EYE SURGERY

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a. Have you ever had eye surgery? (Include Radial Keratotomy (RK), Photo refractive Keratectomy (PRK) or Laser in Situ Keratomileuisi
(LASIK) nrnc.~rljJfesl If "YES"ensure Dre~OD. oDeI~~D exams are included wnhoollsical.
8. SWIMMING ABILITY
a. Can you swim 50 yards using any combination of the crawl . breast, side and!or the back strokes?

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b. Abandon ship jump: Can you jump from a 12-ft tower to simulate abandoning ship?
c. Can you remain afloat for 5 minutes (prone position)? Remain afloat (face down), utilizing survival-floating skills?
d. Shirt and trouser inflation : Can you fill a shirt and pair of trousers with air to remain afloat?

If any of the preceding questions are answered no, ensure that you are issued the "Officer Candidate SchoollOfficer Development School Third Class
Swim Test Letter" and that you initial acknowledgement of the letter.
Applicant's Initials :
9. ILLEGAL ACTIVITIES

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a. Have you ever been charged of a crime to include drug or alcohol use?
b. Have you ever used illegal drugs?
c. Have you ever been charged with domestic violence?
d. Have you ever filed bankruptcy?

10. CURRENT PHYSICAL FITNESS PROGRAM (If none enter N/A)
Fre~guen~

Activity

Date CommencedJYYYYMMMDD)

11. PROFESSIONAL LICENSES (up to 4 licenses) (If none enter N/A)
Expiration Date

License Name

License Name

Expiration Date

12. FLYING EXPERIENCE . ( If none enter N/A)
License!Ratings

l"'eflO

Hours

I

How Acquired (school , family, etg

14. EXTRA CURRICULAR ACTIVITIES/ORGANIZA TIONS/CLUBS/SPORTS HS
t\ctlv lty

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13. FOREIGN LANGUAGESKILLS (If none enter N/A)
Lanquaqe

Model

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1 LaQguclge

J

=High School/C =ColI~e/PC
1f

ears

Proficiency

Post ColleQe
JTTlce Hele

15. APPLICANT'S REMARKS (Limited to the visible area.)

NAVCRUIT 11311238 (REV 7-2010(2» )

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16. APPLICANT'S MOTIVATIONAL STATEMENT (Limited to the visible area.)

I certify that all statements made in this application and any additional statements pertaining thereto are entirely true and complete to the best of my
knowledge and belief. I understand that failure to answer any correspondence accurately or promptly, or failure to accept an appointment tendered to
me will subject my application or appointment to cancellation without further notice.
17. Applicant's Name

\18. Applicant's Signature

\_19. Applicant's

Tele . Number

\20. Date

f,pplicant's Email

NAVCRun 1131/238 (REV 7-2010(2))

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21. OFFICER RECRUIT~R'S REMARKS (Limited to the visible area.)

22. OFFICER PROCESSOR'S SUMMARY (Limited to the visible area.)

23. OFFICER PROGRAMS OFFICER'S REMARKS (Limited to the visible area.)

24. Based upon all available information , it is my opinion that the applicant is recommended as follows for appointment in the U.S . Navy or U. S. Navy
Reserve for the programs listed above in order of preference listed.
('
(' Recommended
('
Highly Recommended
Not Recommended
25. Recruiting Personnel Certification
I certify that the information contained on this document, to include my personal remarks, are true and accurate to the best of my ability.

I also understand that information from this form will be used to create documents for the OFFICIAL PERSONNEL RECORD . ALL information provided

in this document has been verjfied agajns t the pCSJRer s2!ffCe doc uments (ie. Birth Certificates and SSN Cards) and is accurate to include the proper

spelling of the applicant's complete name and SSN.

26 . Date

27 . Recruiter's Telephone Number (Include area code)

28. Recruiter's Name

29 . Date

30. Processor's Telephone Number (Include area code )

31 . Processor's Name

32. Date

33 . OPO's Telephone Number (Include area code)

34 . OPO's Name

NAVCRUIT 1131/238 (REV 7-2010(2»

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