Form Request for Examin Request for Examin USMEPCOM FORM 680-3

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

REQUEST FOR EXAMINATION

OMB No. 0704-0173
OMB approval expires

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.
PRIVACY ACT STATEMENT: AUTHORITY: Sections 505, 508, 510, and 3012 of Title 10 U.S. Code and Executive Order 9397. PRINCIPAL PURPOSE: The requested information on this form will be used to
properly process and identify the individual requesting an examination at a military entrance processing station (MEPS). ROUTINE USE: Record is maintained with other enlistment processing records.
DISCLOSURE: Voluntary; refusal to provide required data could result in denial of enlistment.
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

SPECIAL
CONSULT

INSPECT

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.

RE-EXAM
OTHER

21. APPLICANT'S SIGNATURE
WKID

N E E D S

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

D D 6 7

24. RIGHT THUMBPRINT

Yes

Photo ID? (X one)

If Yes, type/organization:

No

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

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, 20140425 DRAFT

(Bn, NRD, Sq or RS Location)

PREVIOUS EDITION IS OBSOLETE.

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