USMEPCOM FORM 680- Request for Examination

OMB No. 0704-0173
OMB approval expires

REQUEST FOR EXAMINATION

FOR USE OF THIS FORM,
SEE USMEPCOM REG 680-3
FOR OFFICIAL USE ONLY

THE INFORMATION PROVIDED CONSTITUTES AN OFFICIAL STATEMENT.

The public reporting burden for this collection of information is estimated to average 22 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 Headquarters, U.S. Military Entrance Processing Command, Operations Directorate, 2834 Green Bay Road, North Chicago, IL 60064-3094.

Read Privacy Act Statement on back before completing form.
A. SERVICE PROCESSING FOR

B. PRIOR SERVICE

Yes

C. SELECTIVE SERVICE CLASSIFICATION

No

D. SELECTIVE SERVICE REGISTRATION NUMBER

NUMBER OF DAYS
1. SOCIAL SECURITY NUMBER
-

2. NAME (Last, First, Middle Name (and Maiden, if any), Jr., Sr., etc.)

-

3. CURRENT ADDRESS
(Street, City, County, State, Country, ZIP Code)

4. HOME OF RECORD ADDRESS
(Street, City, County, State, Country, ZIP Code)

5. CITIZENSHIP (X one)

6. SEX (X one)
a. MALE

a. U.S. AT BIRTH ( If this box is marked, also X (1) or (2))

8. MARITAL STATUS
(Specify)

(2) BORN ABROAD OF U.S. PARENT(S)

(1) NATIVE BORN
b. U.S. NATURALIZED

7.a. ETHNIC CATEGORY (X one)
b. FEMALE

c. U.S. NON-CITIZEN NATIONAL

d. IMMIGRANT ALIEN (Specify)

(1) HISPANIC OR LATINO

(1) AMERICAN INDIAN/ALASKA NATIVE

(4) NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
(5) WHITE

f. ALIEN REGISTRATION NUMBER (As applicable)

10. DATE OF BIRTH (YYYYMMDD) 11. RELIGIOUS PREFERENCE (Optional)

12. EDUCATION (Yrs/Highest Ed Gr completed)

14. VALID DRIVER'S LICENSE (X one) (If Yes, list State, number, and expiration date)

1st

13. PROFICIENT IN FOREIGN LANGUAGE (X one)
Yes

Yes

(2) ASIAN

(3) BLACK OR AFRICAN AMERICAN

9. NUMBER OF
DEPENDENTS

e. NON-IMMIGRANT FOREIGN NATIONAL (Specify)

(2) NOT HISPANIC OR LATINO

7.b. RACIAL CATEGORY (X all that apply)

No

2nd

(If Yes, specify)

15. PLACE OF BIRTH (City, State, and Country)

No

16. APTITUDE:

a. ASVAB REQUIRED TO ENLIST?
(X one)
Yes
No
b. ENLIST UNDER STUDENT TEST
(X one)
Yes
No

17.a. RECRUITER ID/SSN

20. MEDICAL:

c. TEST TYPE
INITIAL
SPECIAL
CONFIRMATION

e. PREVIOUS TEST VERSIONS

d. RETEST TYPE
1ST RETEST

2ND RETEST

6 MONTH RETEST
IMMED RETEST AUTHORIZED

b. STATION ID

FULL

b. EXAM TYPE

2.

f. PREVIOUS TEST DATES (YYYYMMDD)
2.
1.
19. TEST ADMINISTRATOR SIGNATURE

18. TEST ADMINISTRATOR SSN/ID

a. MEPS MEDICAL EXAM REQUIRED TO ENLIST?
(X one)
Yes
No

1.

SPECIAL
CONSULT

RE-EXAM
OTHER

D R A F T

21. APPLICANT'S SIGNATURE

INSPECT

WKID

23. APPLICANT CERTIFICATION IN PRESENCE OF TEST ADMINISTRATOR
I certify that I am the person identified on this form:

ST

c. DATE LAST FULL MEDICAL
EXAM (YYYYMMDD)
22. MIRS CODING
INT

DATE

DATE

INT

24. RIGHT THUMBPRINT
Yes

Photo ID? (X one)

No

RIGHT THUMBPRINT, FIRST ATTEMPT
(Affix thumbprint with thumbnail pointed to
the left.)

If Yes, type/organization:
ID Number:

(Signature of Applicant)

25. APPLICANT CERTIFICATION IN PRESENCE OF RECRUITING PERSONNEL
I certify that I am the person identified on this form and the information about me shown there, including my Social Security Number is all true and correct to the
best of my knowledge. I also certify that:
a. I have never been tested ANYTIME or ANYWHERE with the ASVAB either for enlistment purposes or as a student under the ASVAB testing program.
at

b. I was tested with the ASVAB on or about
(Most Recent Date Tested)
c. Request for student test scores (high school look-up)

(School, City, and State)
at

(Most Recent Date Tested)

(School, City, and State)

d. Yes, I want to keep my AFQT scores from the student test listed in "c" above.
e. Current or last high school attended

/
OR

(High School)

(13 Digit Code)

/

f.
(Signature of Applicant)

/
(Social Security Number)

(Date)

IF SECOND ATTEMPT IS REQUIRED:
Turn form over (Top of form on the bottom).
Affix right thumbprint on upper right corner,
thumbnail pointed to the left.

MEDICAL RECORDS RELEASE AUTHORITY:
I request and authorize individuals/organizations listed below to release to the MEPS a complete transcript of my medical records. This release is for the purpose of further evaluation of my medical acceptability
under military medical fitness standards. The medical records are to be obtained by this examinee at no cost to the Government and made available for review during the pre-enlistment physical.
26. APPLICANT'S CURRENT MEDICAL INSURER NAME (If none, sign your complete name to affirm
you have no current medical insurer):

27. APPLICANT'S CURRENT MEDICAL PROVIDER NAME (If none, sign your complete name to
affirm you have no current medical provider):

28. MEDICAL INSURER ADDRESS
(Street, City, State, Country, ZIP
Code)

29. MEDICAL PROVIDER ADDRESS
(Street, City, State, Country, ZIP
Code)

30. CERTIFICATION BY RECRUITING PERSONNEL I certify that I have properly identified this applicant in accordance with my service directives, have reviewed for
completeness and accuracy the information provided on this form, and have witnessed the applicant's signature:
/
(Signature of Recruiter (or representative, if authorized))

APPLICANT SSN

/
(Printed/Typed Name of Recruiter or representative)

(Date)

(Printed/Typed Name of Recruiter (if not recorded above))
/
(Recruiter ID/SSN)

/
(Local Recruiting Activity)

USMEPCOM FORM 680-3A-E, 20140902 DRAFT

(Bn, NRD, Sq or RS Location)

PREVIOUS EDITION IS OBSOLETE.

Adobe Designer 9.0

PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; 504, Persons Not Qualified; 505, Regular components:
qualifications, term, grade; and 12102, Reserve Components: Qualifications; 14 U.S.C. 351, Enlistments; term, grade; and 632, Functions and
powers vested in the Commandant; DoDI 1304.2, Accession Processing Data Collection Forms; DoDI 1304.26, Qualification Standards for
Enlistment, Appointment, and Induction; AR 601-270, OPNAVINST 1100.4C Ch-2, AFI 36-2003_IP, MCO 1100.75E, and COMDTINST M 1100.2E,
Military Entrance Processing Station (MEPS); AR 601-210, Active and Reserve Components Enlistment Program; AFPD 36-20; and E.O. 9397, as
amended (SSN).
PRINCIPAL PURPOSE(S): Military recruiters use the information you provide on this form to collect additional information from the individuals,
schools, and employers you list so that we can determine if you meet recruitment standards. If you do meet these standards and enlist, the
information you provide on this form starts your Official Military Personnel File. During the recruiting process we use the information on this form to
verify your identity. This form also contains a section where you are asked to provide your signed consent for your medical provider(s) to release
your medical records to the DoD. While completed forms are covered by recruiting and official military personnel file SORNs maintained by each of
the Services the primary SORN may be found at:
http://dpclo.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/6156/a0601-270-usmepcom-dod.aspx.
ROUTINE USE(S): Information is disclosed to the Selective Service System (SSS) to update the SSS registrant database and may also be
disclosed to local and state Government agencies for compliance with laws and regulations governing control of communicable diseases. The
specific DoD Blanket Routine Uses identified below (and also found at http://dpclo.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx)
also apply to this collection.
01. Law Enforcement Routine Use: If a system of records maintained by a DoD Component to carry out its functions indicates a violation or
potential violation of law, whether civil, criminal, or regulatory in nature, and whether arising by general statute or by regulation, rule, or order issued
pursuant thereto, the relevant records in the system of records may be referred, as a routine use, to the agency concerned, whether federal, state,
local, or foreign, charged with the responsibility of investigating or prosecuting such violation or charged with enforcing or implementing the statute,
rule, regulation, or order issued pursuant thereto.
02. Disclosure When Requesting Information Routine Use: The DoD may disclose your information to a federal, state, or local agency maintaining
civil, criminal, or other relevant enforcement information or other pertinent information, such as current licenses, if necessary to obtain information
relevant to your enlistment request (ie., a DoD decision concerning the hiring or retention of an employee).
04. Congressional Inquiries Disclosure Routine Use: The DoD may disclose your record to your congressperson if your congressional office makes
an inquiry at your request.
09. Disclosure to the Department of Justice for Litigation Routine Use: The DoD may disclose your record to the Department of Justice for the
purpose of representing the Department of Defense, or any officer, employee or member of the Department in pending or potential litigation to
which the record is pertinent.
12. Disclosure of Information to the National Archives and Records Administration Routine Use: The DoD may disclose your record to the National
Archives and Records Administration for the purpose of records management inspections conducted under authority of 44 U.S.C. 2904 and
2906.15. Data Breach Remediation Purposes Routine Use: The DoD may disclose your record to an appropriate agency, entity, or person when
(1) The DoD suspects or has confirmed that the security or confidentiality of the information in the system of records has been compromised;
(2) the DoD has determined that as a result of the suspected or confirmed compromise there is a risk of harm to economic or property interests,
identity theft or fraud, or harm to the security or integrity of this system or other systems or programs (whether maintained by the DoD or another
agency or entity) that rely upon the compromised information; and (3) the disclosure made to such agencies, entities, and persons is reasonably
necessary to assist in connection with efforts to respond to the suspected or confirmed compromise and prevent, minimize, or remedy such harm.
DISCLOSURE: Voluntary. However, if you fail to provide the requested information you might not be able to enlist. Your Social Security Number
is used during the recruiting process to conduct background screening (e.g., law enforcement, medical, or educational records checks; former
employer checks, work status, etc.), keep all of your records together during the enlistment process, and ensure your test results are properly
recorded.

D R A F T

Applicable SORNs:
Accession:
U.S. Military Processing Command
(http://dpclo.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/6156/a0601-270-usmepcom-dod.aspx)
Army (http://dpclo.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/6131/a0600-8-104-ahrc.aspx)
Navy (http://dpclo.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/6411/n01131-1.aspx;
http://dpclo.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/6413/n01133-2.aspx)
Marine Corps (http://dpclo.defense.gov/Privacy/SORNsIndex/DODComponentArticleView/tabid/7489/Article/6777/m01133-3.aspx)
Air Force (http://dpclo.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/5820/f036-aetc-r.aspx)
Coast Guard (http://edocket.access.gpo.gov/2008/E8-29845.htm)
Official Military Personnel Files:
Army (http://dpclo.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/6128/a0600-8-104b-ahrc.aspx;
http://dpclo.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/6129/a0600-8-104b-ngb.aspx)
Navy (http://dpclo.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/6405/n01070-3.aspx)
Marine Corps (http://dpclo.defense.gov/Privacy/SORNsIndex/DODComponentArticleView/tabid/7489/Article/6775/m01070-6.aspx)
Air Force (http://dpclo.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/5876/f036-af-pc-c.aspx)
Coast Guard (http://edocket.access.gpo.gov/2008/E8-29793.htm)

USMEPCOM FORM 680-3A-E (BACK), 20140902 DRAFT