Accepted Candidate Procedures

USMA ADMISSIONS PROCEDURES

Accepted Candidate Procedures Screenshots - December 2019

Accepted Candidate Procedures

OMB: 0702-0060

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0702-0060 can be found here:

2022-03-30 - Revision of a currently approved collection

Document [pdf]

Download: pdf | pdf

OMB No. 0702-0060
OMB Approval Expiration
MMM DD, YYYY
AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information, 0702-0060, is estimated to average 251 minutes (195 minutes for the Candidate Phase and 56
minutes for the Accepted Candidate phase) 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 the burden estimate or burden reduction suggestions to
the Department of Defense, Washington Headquarters Services, at [email protected]. Respondents should be aware
that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display
a currently valid OMB control number.
PRIVACY ACT STATEMENT AUTHORITY: Title 5 United Sates Code, Government Organization and Employees, Ch 403, Sec 4346; Ch 505, Sec 5031; Ch 603, Sec 6958; Title
44, United States Code, Public Printing and Documents, Ch 31, Sec 3101; Executive Order 9397, Numbering System for Federal Accounts Relating to Individual Persons.
PRINCIPAL PURPOSE: Collection of data on Academy candidates for opening a file. ROUTINE USE: To gather information on a candidate in order to open a file for admissions to
the United States Military. DISCLOSURE IS VOLUNTARY. However, failure to provide information could preclude appointment. In addition to those disclosures generally
permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, these records contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5
U.S.C. 552a(b)(3) as follows: Academic transcripts may be provided to educational institutions for the purpose of admissions to further educational degree programs. The
DoD Blanket Routine Uses set forth at the beginning of the Army's compilation of systems of records notices also apply to this system.

INSTRUCTIONS: The instructions for completing all required portions should be followed closely to ensure accurate data collection, and to preclude over-collection of information.
Instructions for completing all the required forms can be found in the Instructions of Applicants Offer Admissions booklet located on the candidate portal page.

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ERIC W. CORTI, USMA Class of 2023

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OMB No. 0702-0060
OMB Approval Expiration
MM DD, YYYY

CERTIFICATE OF AUTHORIZATION
AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information, 0702-0060, is estimated to average 3 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 the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at [email protected]. Respondents should be aware that notwithstanding any other provision of law, no person shall be
subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PRIVACY ACT STATEMENT AUTHORITY: Title 5 United Sates Code, Government Organization and Employees, Ch 403, Sec 4346; Ch 505, Sec 5031; Ch
603, Sec 6958; Title 44, United States Code, Public Printing and Documents, Ch 31, Sec 3101; Executive Order 9397, Numbering System for Federal
Accounts Relating to Individual Persons. PRINCIPAL PURPOSE: Collection of data on Academy candidates for opening a file. ROUTINE USE: To gather
information on a candidate in order to open a file for admissions to the United States Military. DISCLOSURE IS VOLUNTARY. However, failure to provide
information could preclude appointment. In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, these
records contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: Academic transcripts
may be provided to educational institutions for the purpose of admissions to further educational degree programs. The DoD Blanket Routine Uses set forth
at the beginning of the Army's compilation of systems of records notices also apply to this system.

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INSTRUCTIONS:
The instructions for completing the Certificate of Authorization should be followed closely to ensure accurate data collection, and to preclude over-collection
of information.
Instructions for completing the Certificate of Authorization can be found in the Instructions for Applicants Offered Admissions booklet located on
the candidate portal page.

I hereby appoint the United States Military Academy Cadet Accounting Services Office and his/her
successor or designee, as custodian and trustee of the initial deposit made by me and the total
pay and allowances accruing to me by reason of my appointment to, and duty as, a Cadet at the
United States Military Academy. Said custodian shall have the power to deposit said pay and
allowances in an account maintained for my use and benefit in such depository as he/she may
deem to be in my best interest.

The custodian shall have full authority to invest said funds and to use and/or expend said funds, or
any part thereof, for any interest and dividends generated by the Cadet Personal Trust Fund may be
used to pay the administrative cost of maintaining the Fund, including the salaries or any persons
directly employed by the Fund, whose salaries are not paid with appropriated funds. This certificate
of authorization is voluntarily made and shall be and remain in full force and effect during the entire
period of my appointment to, and duty as, a Cadet at the United States Military Academy unless
sooner revoked.

PRINT NAME (LAST, FIRST, MIDDLE [JR, II, ECT]

DATE

USMA Form 6-154 December 2019

SOCIAL SECURITY NUMBER

SIGNATURE

OMB No. 0702-0060
OMB Approval Expiration
MM DD, YYYY

STATEMENT OF CONSENT
AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information, 0702-0060, is estimated to average 5 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 the burden estimate or burden reduction
suggestions to the Department of Defense, Washington Headquarters Services, at [email protected]. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject
to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

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PRIVACY ACT STATEMENT AUTHORITY: Title 5 United Sates Code, Government Organization and Employees, Ch 403, Sec
4346; Ch 505, Sec 5031; Ch 603, Sec 6958; Title 44, United States Code, Public Printing and Documents, Ch 31, Sec 3101;
Executive Order 9397, Numbering System for Federal Accounts Relating to Individual Persons. PRINCIPAL PURPOSE:
Collection of data on Academy candidates for opening a file. ROUTINE USE: To gather information on a candidate in order to
open a file for admissions to the United States Military. DISCLOSURE IS VOLUNTARY. However, failure to provide
information could preclude appointment. In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the
Privacy Act of 1974, these records contained therein may specifically be disclosed outside the DoD as a routine use pursuant
to 5 U.S.C. 552a(b)(3) as follows: Academic transcripts may be provided to educational institutions for the purpose of
admissions to further educational degree programs. The DoD Blanket Routine Uses set forth at the beginning of the Army's
compilation of systems of records notices also apply to this system.
INSTRUCTIONS:
The instructions for completing the Statement of Consent should be followed closely to ensure accurate data collection, and to
preclude over-collection of information.

Instructions for completing the Statement of Consent can be found in the Instructions of Applicants Offer Admissions booklet
located on the candidate portal page.

I/We certify that
is not yet 18 years of age and has no
other legal guardian than me/us. I/We have read the entire contents of USMA 5-50. USMA form
5-50 consists of the Oath of Allegiance, the Agreement to Serve, and an affirmation of marital
status, child support, spousal support, and custody obligations; thereby obligating my/our son/
daughter in accordance with those terms.
Candidate's Social Security Number:

Date:

PARENT/LEGAL GUARDIAN
USMA Form 5-519 December 2019

OTHER PARENT/LEGAL GUARDIAN

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OMB No. 0702-0060
OMB Approval Expiration
MM DDD, YYYY

USMA Immunizations Record Form

AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information, 0702-0060, is estimated to average 15 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 the
burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters
Services, at [email protected]. Respondents should be aware that
notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a
collection of information if it does not display a currently valid OMB control number.

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PRIVACY ACT STATEMENT

AUTHORITY: 32 CFR § 575.2, Admission; general and § 575.3, Appointments; sources of nominations. T AR
600-20, Army Policy Command, AR 40-562, Immunizations and Chemoprophylaxis for the Prevention of
Infectious Diseases, AR 40-66, Medical Record Administration and Healthcare Documentation, AR 40-501,
Standards of Medical Fitness. PRINCIPAL PURPOSE(S): To document the immunizations required to enroll
candidates into the United States Military Academy and to promote a safe academic environment. ROUTINE
USE(S): USMA may release information without prior consent within USMA when needed to perform an official
duty, IAW 5 U.S.C. § 552a (b)(1). USMA also may release information outside the USMA, in accordance with 5
U.S.C. section 552a (b) (2-12), and the “Blanket Routine Uses,” published at http://www.defenselink.mil/privacy/
notice/osd.

DISCLOSURE: Disclosure to the Agency of the information requested on this form is voluntary; but failure to
provide all requested information may result in the delay or denial of candidate enrollment and admission.

**USMA - Questions regarding this form may be addressed to the Mologne Cadet Health
Clinic at (845) 938-3003**
** USMAPS (Preparatory School) - Questions regarding this form may be addressed to
KACH Immunizations Clinic at (845) 938-8476**

Do not return this page with the forms. This is an informational page only.

USMA Immunizations Record Form
1. All listed immunizations are required to be medically cleared for entrance into USMA.
2. If additional vaccines are received following submission of this form, send in all updates.
3. Attach to this completed form a legible copy of your original immunizations record.
4. Return completed USMA Form 40-1, MEDCOM Form 829 (and 830 if applicable), and a
copy of your original immunizations record to the appropriate clinic either by e-mail or fax:
* USMA - Mologne Cadet Health Clinic
[email protected] - or - Fax (845) 938-5777
* USMAPS (Prep School) - Keller Army Community Hospital Immunizations Clinic
[email protected] - or - Fax (845) 938 1132

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5. Questions? See attached vaccine guidance as well as FAQ's.

If your question is not answered you may contact the appropriate clinic:
* USMA: (Mologne Cadet Health Clinic: (845)-938-3003

* USMAPS (Prep School): Keller ACH Immunizations Clinic (845)-938-8476
6. For all dates please use DDMMMYYY format. Example: 02JUL2018

Last Name:

Part I - Completed by Candidate (Please Print Clearly)

First Name:
SSN:

MI:
Date of Birth

DDMMMYYYY

Home Telephone Number:

Gender (M/F)

Additional Information:

State of Residence ____________________

Age on R-Day _______________

I have read and understand the above instructions. I understand that all immunizations are
required for admission.
Candidate Signature: ________________________________ Date: _________________
Initial here if you consent to a nurse at Keller Army Community Hospital discussing
your immunizations record with a parent/guardian. This is optional but often
facilitates completion of your immunizations if there are questions.
USMA FORM 40-1 (26 Sept 18) Previous Editions Obsolete.

Name (Last, First, MI________________________________ Date of Birth ___________________
Part II - Completed by Primary Care Provider (Please Print Clearly)

PLEASE USE (DDMMMYYYY) FORMAT

INSERT DATE VACCINE WAS RECIEVED AND ATTACH ANY TITERS DRAWN IN PLACE OF VACCINATIONS

Hepatitis A (Hep A)

PPD

Hepatitis A and B
(TwinRX)

Hepatitis B (Hep B)

(If indicated by MEDCOM
Form 829)

______________

(IPV) Required by DOD after age 18
1

______________

Leave blank if not yet 18y/o

POS / NEG

(MMR)

After age 16

1 ______________

1 _______________

2 ______________

Type ______________

HPV

(optional, not required)

One Tdap Required - List Most Recent Tdap

If TD was given after Tdap, list most recent TD

Varicella (Chicken Pox)

______________

1 ______________

______________

2 ______________

______________

1 ______________ Type: Tdap

Allergies

mm __________

Meningococcal ACWY

Tetanus, Diphtheria, and Pertussis

1 ______________ Type: TD

__________

Measles, Mumps, Rubella

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Inactivated Polio Vaccine

____ Titers Attached

1 _______________________________ Reaction _________________________________
2 _______________________________ Reaction _________________________________
3 _______________________________ Reaction _________________________________
4 _______________________________ Reaction _________________________________
Primary Care Provider Signature: __________________________________________
Primary Care Provider Name: ________________________________________________
Office Address: __________________________________________________________
Telephone Number: _____________________________________________________
USMA FORM 40-1 (26 Sept 18) Previous Editions Obsolete.

VISION EXAM

OMB No. 0702-0060
OMB Approval Expiration
MM DD, YYYY

AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information, 0702-0060, is estimated to average 5 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 the
burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters
Services, at whs.mc-alex.esd.mbx.dd-dod-information- collections @mail.mil. Respondents should be aware that
notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a
collection of information if it does not display a currently valid 0MB control number.

INSTRUCTIONS:

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PRIVACY ACT STATEMENT AUTHORITY: Title 5 United Sates Code, Government Organization and Employees, Ch
403, Sec 4346; Ch 505, Sec 5031; Ch 603, Sec 6958; Title 44, United States Code, Public Printing and Documents, Ch
31, Sec 3101; Executive Order 9397, Numbering System for Federal AccQunts Relating to Individual Persons.
PRINCIPAL PURPOSE: Collection of data on Academy candidates for opening a file. ROUTINE USE: To gather
information on a candidate In order to open a file for admissions to the United States Military. DISCLOSURE IS
VOLUNTARY. However, failure to provide information could preclude appointment In addition to those disclosures
generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, these records contained therein may
specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: Academic
transcripts may be provided to educational Institutions for the purpose of admissions to further educational
degree programs. The DoD Blanket Routine Uses set forth at the beginning of the Anny's compilation of systems of
records notices also apply to this system.

The instructions for completing the Vision Survey should be followed closely to ensure accurate data collection,
and to preclude over-collection of information.
Instructions for completing the Vision Survey can be found below.

PART I. You must complete all items in this section, whether or not you wear eyeglasses or contact lenses.
PART II. Your Optometrist or Eye Physician must complete all items in this section so the West Point Eye Clinic can
order two pairs of military glasses and one EyePro insert for you prior to your arrival.

SPECIAL INSTRUCTIONS TO EYE DOCTOR
Spectacle Prescription: Even if your patient wears contact lenses full or part time, please complete the eyeglass
prescription in MINUS cylinder form which provides the best full-time wear distance visual acuity.
Frame size: The frame to be provided at West Point will be a medium weight, black plastic frame. It is S-10 shape
(10mm difference between vertical and horizontal lens dimensions.) If patient presently wears a frame of a
different style, write in the actual or estimated plastic frame size. Be sure to Include PD (Required). Standard base
curves will be ordered unless otherwise specified.
THIS FORM SHOULD REACH USMA NOT LATER THAN THE THIRD FRIDAY IN MAY. LATE APPOINTEES: PLEASE MAIL
AS SOON AS POSSIBLE.

USMA Form 5-490 December 2019

OMB No. 0702-0060
OMB Approval Expiration
MM DD, YYYY

PART I
1.

Name of Candidate (Last, First): _________________________________

SSN: _________________________________

Sex:

Are glasses or contact lenses required for clear or comfortable vision?

M
a.

F
YES

(If YES, you are urged to have PART II completed by your Optometrist, or complete information
using most recent spectacle prescription.)

PART II

Recommended Frame Size:
PD: ______

PRISM

ADD

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Spectacle Prescription (In Minus Cylinder Form)
SPHERE
CYL
AXIS
OD
OS
S (46)

S (48)

M (50)

L (52)

DIST VA
20/
20/
L (54)

*PD is required. If PD measurement is blank, please go to local Optometrist or Optical Center to receive this
information.

Remarks: _____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

__________________________

__________________

Signature and Title of Examiner

Address

Date of Exam

___________________________

USMA Form 5-490 December 2019

OMB No. 0702-0060
OMB Approval Expiration
MMM DD, YYYY

POLICE RECORD CHECK
AGENCY DISCLOSURE NOTICE

The public reporting burden for this collection of information, 0702-0060, is estimated to average 5 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 the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at [email protected]. Respondents should be aware that notwithstanding any other provision of law, no person shall be
subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.
PRIVACY ACT STATEMENT AUTHORITY: Title 5 United Sates Code, Government Organization and Employees, Ch 403, Sec 4346; Ch 505, Sec 5031; Ch 603, Sec 6958; Title 44, United States Code, Public Printing and Documents, Ch 31, Sec 3101; Executive Order 9397, Numbering System for Federal
Accounts Relating to Individual Persons. PRINCIPAL PURPOSE: Collection of data on Academy candidates for opening a file. ROUTINE USE: To gather information on a candidate in order to open a file for admissions to the United States Military. DISCLOSURE IS VOLUNTARY. However, failure to
provide information could preclude appointment. In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, these records contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: Academic transcripts
may be provided to educational institutions for the purpose of admissions to further educational degree programs. The DoD Blanket Routine Uses set forth at the beginning of the Army's compilation of systems of records notices also apply to this system.
The instructions for completing the Police Record Check should be followed closely to ensure accurate data collection, and to preclude over-collection of information.
Instructions for completing the Police Record Check can be found in the Instructions of Applicants Offer Admissions booklet located on the candidate portal page.

SECTION I-To be completed by applicant.
1. NAME OF APPLICANT (Last, First, Middle)

4. DATE OF BIRTH

2. SEX
Male
Female

3. PLACE OF BIRTH
a. City
b. County

5. RACE

6. SSN

a. Amer. Indian/Alaskan Native
b. Asian
c. Black or African American

7. ADDRESS
a. NUMBER & STREET/APT. NO.

c. State

8. DATES AT THIS ADDRESS
c. STATE a. FROM
b. TO

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b. CITY

d. Native Hawaiian or other Pacific Islander
e. White

The data are for OFFICIAL USE ONLY and will be maintained and used in strict confidence in accordance with federal law and regulations. Making a knowing
and willing false statement on this USMA Form 5-521 may be punishable by fine or imprisonment or both. All information provided by you, which possibly
may reflect adversely on your past conduct and performance, may have an adverse impact on you in your military career in situations such as consideration
for special assignments, security clearances, court martial and administrative proceedings, etc.

9. I HEREBY CONSENT TO RELEASE FROM YOUR FILES THE INFORMATION REQUESTED BELOW
SIGNATURE
DATE

SECTION II: (TO BE COMPLETED BY POLICE OR JUVENILE AGENCY)

The person described above, who claims to have resided at the address shown above, has applied to the United States Military
Academy at West Point. Please furnish from your files the information relative to Section II below. A return envelope is
provided for your convenience.

10. HAS THE APPLICANT A POLICE OR JUVENILE RECORD, TO INCLUDE MINOR TRAFFIC VIOLATIONS?
YES If Yes, what was the offense or charge, date, disposition and sentence? Explain below.
NO

11. IS THE APPLICANT NOW UNDERGOING COURT ACTION OF ANY KIND?
If yes, give details.

MAIL TO:
DIRECTOR OF ADMISSIONS
UNITED STATES MILITARY ACADEMY
OFFICIAL MAIL & DISTRIBUTION CENTER
646 SWIFT ROAD
WEST POINT, NY 10996-1905

USMA FORM 5-521 December 2019

YES

THIS IS TO CERTIFY THAT THE ABOVE DATA AS
CORRECTED ARE TRUE AND CORRECT ACCORDING TO
THE RECORD ON FILE IN THIS OFFICE. THIS INFORMATION
IS CONFIDENTIAL AND CANNOT BE USED IN ANY OTHER
MANNER EXCEPT FOR OFFICIAL PURPOSES.
12. DATE

13. TITLE

14. VERIFIED BY (Signature)

OMB No. 0702-0060
OMB Approval Expiration
MM DD, YYYY

REQUEST FOR FINAL TRANSCRIPT
AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information, 0702-0060, is estimated to average 5 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 the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at [email protected]. Respondents should be aware that notwithstanding any other provision of law, no person shall be
subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

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INSTRUCTIONS:
The instructions for completing the Request for Final Transcript should be followed closely to ensure accurate data collection, and to preclude overcollection of information.

PRINT NAME (FIRST, MIDDLE, LAST [JR, II, ECT]

SOCIAL SECURITY NUMBER

The student named above has been accepted for admission to the United States Military Academy. To complete the
file, it is necessary that we have a copy of the final senior year grades and the final four-year grade-point average.
Please complete this form as accurately as possible and submit it, WITH A COPY OF THE FINAL SENIOR YEAR
GRADES, as soon as the current academic year ends. A pre-addressed, postage-free envelope is provided.

_________________________________________
School Phone Number

________________________________________

_________________________________________

Address

________________________________________
Official High School Name

____________________________________

_________________________

_____________________________

City

State

Zip Code

_________________________

____________________________________________________

Candidate's Final (Cumulative) GPA

Indicate How GPA Was Determined

_________________
DATE

________________________________
SIGNATURE

___________________________________
Title

Send to United States Military Academy Admissions, 646 Swift Road, West Point, NY 10996-1905

USMA Form 6-153 December 2019

JUMPS - JSS PAY ELECTIONS
For use of this form, see AR 37-104-3; the proponent agency is ASA(FM)

Authority:
Principal Purpose:
Routine Use:
Disclosure:
1.

PRIVACY ACT STATEMENT
Title 37 USC, Section 101.
To provide the service member a means of electing the manner in which he or she desires to receive pay and allowances.
To establish the pay account of the MMPF.
Disclosure of your social security number (SSN) and other personal information is voluntary; however, without the
requested information, the Finance Office cannot identify members, or take the requested action.

HOW DO YOU WANT TO BE PAID? (X one item.)

METHOD OF PAYMENT (X one item.)

a. Once a Month

a. Sure Pay/Direct Deposit (Complete Section 4.)

b. Twice a Month

b. Check to Address (Complete 5.)

HELD PAY (NOTE: All amounts may be withdrawn at any time upon application to your Finance
Officer.)

SPECIFY AMOUNT

a. If a held pay amount is also desired, check box and enter amount.
4.

SURE PAY/DIRECT DEPOSIT (X one box.)
a. SF 1199A attached. (Complete items (1) through (5)) .

b. SF 1199A on file. (Use this box if you already have
SURE PAY/DIRECT DEPOSIT to this financial institution)
(Do not complete items (1) through (5)).

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(1) NAME OF FINANCIAL ORGANIZATION

(3)

NAME OF ACCOUNT HOLDER

(4) STREET NO., RR NO., P.O. BOX

(5)

CITY, STATE, ZIP CODE (Or Country)

(2) SAVINGS OR CHECKING ACCOUNT NO

CHECK TO ADDRESS (Provide complete mailing address.)

STREET NO., RR NO., P.O. BOX

CITY

STATE

ZIP CODE

COUNTRY

6. REMARKS

I HEREBY AUTHORIZE PAYMENT AS SPECIFIED ABOVE.

TYPED OR PRINTED NAME

SSN

SIGNATURE

DA FORM 3685, SEP 1990

NAME AND ADDRESS OF ORGANIZATION

DATE

DA FORM 3685-R, APR 90 IS OBSOLETE

APD LC v3.00ES

Tattoo Data Form

OMB No. 0702-0060
OMB Approval
Expiration MMM DD,
YYYY

AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information, 0702-0060, is estimated to average 5 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 the burden estimate or burden reduction
suggestions to the Department of Defense, Washington Headquarters Services, at [email protected]. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to
any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

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PRIVACY ACT STATEMENT AUTHORITY: Title 5 United Sates Code, Government Organization and Employees, Ch
403, Sec 4346; Ch 505, Sec 5031; Ch 603, Sec 6958; Title 44, United States Code, Public Printing and Documents, Ch 31, Sec
3101; Executive Order 9397, Numbering System for Federal Accounts Relating to Individual Persons. PRINCIPAL
PURPOSE: Collection of data on Academy candidates for opening a file. ROUTINE USE: To gather information on a
candidate in order to open a file for admissions to the United States Military. DISCLOSURE IS VOLUNTARY. However,
failure to provide information could preclude appointment. In addition to those disclosures generally permitted under 5
U.S.C. 552a(b) of the Privacy Act of 1974, these records contained therein may specifically be disclosed outside the DoD as a
routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: Academic transcripts may be provided to educational institutions for
the purpose of admissions to further educational degree programs. The DoD Blanket Routine Uses set forth at the beginning
of the Army's compilation of systems of records notices also apply to this system.
INSTRUCTIONS:
The instructions for completing the Tatoo Questionnaire should be followed closely to ensure accurate data collection, and to
preclude the over-colection of information
Instructions: Please carefully review the policy below and complete the questionnaire.Additional instructions for completing the
Tatoo Data from can be found in the in the Instructions of Applicants Offer Admissions booklet located on the candidate portal page.

Army Regulation 670-1 dictates the Wear and Appearance of Army Uniforms and Insignia.
Below is a synopsis of the Army’s tattoo policy, as well as a description of tattoos that are not
authorized for Soldiers to have.

TATTOO POLICY
Unauthorized tattoo locations:
x On the head, face, & neck, (anything above the T-shirt line to include on/inside the
eyelids, mouth, & ears)
x On the hands, fingers, wrists (below the wrist bone)
x Each visible tattoo below the elbow or below the knee must be smaller than the size of
the wearer’s hand (with fingers extended & joined with the thumb touching the base of
the index finger)
x Soldiers may have no more than 4 total visible tattoos (smaller than the size of the
wearer’s hand) below the elbow or below the knee
CATEGORIES OF UNAUTHORIZED TATTOOS
x Extremist tattoos or brands are those affiliated with, depicting, or symbolizing extremist
philosophies, organizations, or activities.
x Indecent tattoos or brands are those that are grossly offensive to modesty, decency,
propriety or professionalism.
x Sexist tattoos or brands are those that advocate philosophy that degrades or demeans a
person based on gender but may not meet the same definition of “indecent.”
x Racist tattoos or brands are those that advocate a philosophy that degrades or demeans a
person based on race, ethnicity, or national origin.
Candidate Name: ____________

Candidate ID: _____________

Yes
1. Do you have a tattoo(s)?
If no, please go to the bottom of this questionnaire.

2. If so, how many tattoos do you have?

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3. 3OHDVHFLUFOHWKHDSSURSULDWHDUHDRI\RXUERG\RQWKHVLOKRXHWWHVEHORZZKHUHWKHWDWWRRV
DUHORFDWHG

4. Please provide a brief description of your tattoo(s).

Any tattoos, or lack thereof, will be documented and verified upon arrival to the United States
Military Academy on Reception Day (R-Day).

File Type	application/pdf
File Title	PowerPoint Presentation
Author	IETD
File Modified	2019-12-11
File Created	2017-04-24