CGRC-1132 (02/17) USCG "Chat Now" Questionnaire

OMB Control #: 1625-new

Expiration Date: mm/dd/yyyy

United States Coast Guard “Chat Now” Questionnaire
Please complete this information to chat with a recruiter
[Questions will only be deployed online. Upon submission, the person who completes will be connected to a recruiter in
an online instant message format]

Paperwork Reduction Act Statements
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays
a valid OMB control number. The Coast Guard estimates that the average burden to complete this form is 5 minutes. You
may submit any comments concerning the accuracy of this burden estimate or any suggestions for reducing the burden to:
Commanding Officer, Coast Guard Recruiting Command, 2703 Martin Luther King Jr. Ave SE, Washington, DC 20593-7419
or Office of Management and Budget, Paperwork Reduction Project (1625-new), Washington DC 20503.

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.

I have read and understand my privacy rights (for an explanation, visit gocoastguard.com/privacy-policy):
[Upon answering “Yes”, the “Initial Information” questions will appear]

Initial Information
Middle:
Name: First:
Email Address:
Do you have a Recruiting Question or a General question?

Last:

Suffix:
Zip Code:

 Select “Recruiting” to ask a recruiting question, explore USCG career opportunities, or determine
initial eligibility. You'll be asked to provide information that helps us answer your recruiting question.
 Select “General” to ask a general (non-recruiting) question.
[Upon answering “Recruiting”, the below questions appear. Upon answering “General”, the chat session begins]

Additional Personal Details
Phone Number:
Birth Date:
Gender:
Ethnicity:
Race #1:
Race #2:
U.S. Citizenship Status:
Education (Highest Attained):
Do you have a criminal charge pending?
Have you been convicted of a felony, major misdemeanor,
domestic violence, or any sex related offense?
Do you have any medical or personal issues or concerns that you would like to discuss that might hinder or
prevent you from being able to serve in the U.S. Coast Guard?

[Upon completing this section, the chat session will begin]

Recruiter Section
Recruiter Assigned:
Recruiter Comments/Notes:

Date of Chat:

CGRC-1132 (02/17)
CLEAR ENTIRE FORM