Form CGRC-1130 (01/17) CGRC-1130 (01/17) United States Coast Guard Prospect Questionnaire /Instru

United States Coast Guard Prospect Questionnaire
Please fill out this information and return to your local recruiting office via mail or fax (please do not email
this form to your recruiter). Locate your local recruiting office via our Find A Recruiter link:
http://www.GoCoastGuard.com/about-us/find-recruiter (do not email this form to your recruiter).
You may also deliver this form in person to your local recruiting office, but please call ahead to make sure a
recruiter will be available.

Date form completed:
Contact Details and Interest
Last:
Middle:
Name: First:
Street Address (No PO Box):
City:
Current Country:
Address:
Email Address:
Phone Number:
How did you first hear about us?
Component:
Programs of Interest:

Maiden:
State:
Zip:
County:

Biographical Details
Social Security Number:
Citizenship Status:
Alien Registration “Green Card” Number (Lawful Permanent Resident only):
Race #1:
Ethnicity:
Race #2:
Age:
Date of Birth (mm/dd/yyyy):
Gender:
Birth
Info:
Country:
County:
City:
State:
Marital Status (select one):
Number of Dependent Children:
Height:
Weight (in lbs):
Hair Color:
Eye Color:
Education (Highest Attained):
High School (Last Attended):
#2:
School / Community Activity #1:
Degree Type:
College (current / last attended):
Current GPA (for most recent education):
Major (if applicable):
Current Education Status:
Current Employment Status:
Number of College Credits:
Total Years of Education (including high school):
Number:
State:
Expiration Date:
Driver’s License
Selective Service Number (males ages 18-26. To obtain a number, go to www.sss.gov):

Military and ASVAB Information
Have you ever talked to a Coast Guard Recruiter?
If yes, when and where?
Have you served or are you currently serving in
Branch:
Component:
another military branch?
If Currently Serving:
If Discharged:
Remaining Service Obligation:
Date of Separation: Type of Discharge/Character of Service:
Years:
Months:
Days:
Anticipated Separation Date:
RE Code:
Pay Grade at Separation:
Time in Service (prior or current service members)
Years:
Months:
Days:
Highest Pay Grade Achieved:
Rate/MOS/Job (in layman’s terms):
Have you ever been rejected from joining another military service?
If Yes, which branch (including Coast Guard), what was the reason, and where did it happen?
ASVAB
Test

Have you ever taken the ASVAB?
Location (name of School/MET Site/MEPS):

CGRC-1130 (01/17)

OMB Control # 1625-XXXX

When:

Score:
Branch for or N/A:

Expiration Date: XX/XX/XXXX

Additional Background Information
Have you ever been arrested, charged, or
convicted of a crime (whether as a juvenile or
an adult), including cases which are expunged
or pending?
Have you had any tickets in the last 5 years,
including parking, traffic violations, sticker/
registration violations, DUI/DWI, etc?

If yes, please briefly explain. Include appx dates:

If yes, please list violations by type. Including appx dates:

How Many:
Do you have any legal action pending, including If yes, please explain:
court cases, lawsuits, child support or custody
adjudications, etc?
How many
Appx Date
Have you ever used, possessed, If yes, please list which substances:
Last Used?
or experimented with illegal
times?
drugs?
Do you have any Tattoos,
If yes, please describe (include size, content, and location):
Piercings, Gages, Brandings
or Mutilations?
Overdue/late payments or
Declared
Do you pay child support or alimony?
Finances. Have
payments in collection (ex: phone, Bankruptcy?
you had any of
medical, etc):
How Much (per month):
the following:
List by company. Include what the debt is for, total owed, & monthly payment
1:
List all debts.
2:
Include credit cards,
car payment,
3:
mortgage, student
4:
loans, cell phone, etc. 5:
6:
Do you object to carrying firearms/weapons to perform Coast Guard duties?
Do you have any religious or other beliefs prevent you from being available for duty 24/7?
Are you afraid of the water?
Rate your swimming confidence:
Have you participated in any of the following activities (select all that apply)?
Boy Scouts
Girl Scouts
Sea Scouts
Police Explorers
Civil Air Patrol
Naval Sea Cadet Corps
Coast Guard Auxiliary

Sea Explorers

ROTC/JROTC

Medical Information

Please list any current or past* chronic medical conditions (such as orthopedic, mental health, surgeries, allergies,
or asthma) and any prescription medications you have taken. *For past conditions, please provide estimated dates.

Recruiter Section
Recruiter Assigned:
Screening/Interview Date (and who if different from Assigned Recruiter):
Comments /
Notes:
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. §§ 504, 1475-1480; 14 U.S.C. §§ 211, 350, 632; Homeland Security Presidential Directive (HSPD) 12.
PURPOSE: To identify and process individuals interested in applying for enlistment or commission in the United States Coast Guard (CG) or CG
Reserve.
ROUTINE USES: Authorized CG personnel will use this information to assess an individual’s interest for enlistment and/or commissioning, to
screen qualified applicants, and to initiate pay and benefits for new members. Any external disclosures of data within this record will be made in
accordance with DHS/USCG-014, Military Pay and Personnel System of Records, 76 Federal Register 66,933, October 28, 2011.
DISCLOSURE: Disclosure is voluntary. However, failure to provide requested information may result in not being contacted by a recruiter and
ultimately, prohibit enlistment or commissioning.

CGRC-1130 (01/17)

OMB Control # 1625-XXXX

Expiration Date: XX/XX/XXXX

CLEAR ENTIRE FORM

Optional Additional Explanations
You may use this space to explain any of the above answers more fully, if necessary.

CGRC-1130 (01/17)

OMB Control # 1625-XXXX

Expiration Date: XX/XX/XXXX

CLEAR ENTIRE FORM