CGRC-1131 Officer Application Form

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Expiration Date: 09/30/2021

OMB Control #: 1625-0128

DEPARTMENT OF HOMELAND SECURITY UNITED STATES COAST GUARD

OFFICER PROGRAM APPLICATION
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: Requested in accordance with 10, U.S.C. § 503, to identify and process individuals interested in applying for a
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 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 Fed. Reg. 66,933, Oct. 28, 2011.
Disclosure: Disclosure is voluntary. However, failure to provide requested information may result in not being contacted by a
recruiter and ultimately, prevent commissioning. Any information you provide is protected from unauthorized disclosure by the
Privacy Act of 1974.
PAPERWORK REDUCTION ACT STATEMENT
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 30 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.
SECTION I: PERSONAL INFORMATION
1. Name (Rate/Rank Last, First, Middle Initial):
3. Gender:

2. Date of Birth:

4. Race:

7. EMPLID:

5. Ethnic Category:

8. U.S. Citizen:

9. Marital Status:

11. Recruiting Office:

6. SSN:
10. Number of Dependents:

12. Recruiter (Rate/Rank, Last, First):

13. Program:

14. Coast Guard Member:

15. Commission:

16. Current Unit:

17. ESO:

18. Home Address:
19. City:
23. Primary Phone:

20. State:

21. Zip code:

22. Personal Email:

24. Secondary Phone:

25. Secondary Email:

26. Anticipated Address:
27. City:

28. State:

29: Zip Code:

30. Future Phone:

SECTION II: EDUCATION
31. Undergraduate College:
34. Cumulative GPA:

32. Degree:
35. Date Degree Awarded/Anticipated:

33. Major:
36. College Semester Hrs Completed:

37. College Transferring to:

38. Degree:

40. Qualifying Test Type and Score:

41. AUP Program Status:

42. Graduate College:
45. Cumulative GPA:

43. Degree:

39. Major:
44. Major:

46. Date Degree Awarded/Anticipated:
SECTION III: MILITARY SERVICE (IF APPLICABLE)

47. Total Active Duty Time:

48. Total Reserve Time:

50. Current Service

49. Total Flight Time:

51a. Previous Service

51b. Previous Service

Branch:

Branch:

Branch:

Officer/Enlisted:

Officer/Enlisted:

Officer/Enlisted:

Status:

Status:

Status:

Date of Entry:

Date of Entry:

Date of Entry:

Ant. End Date:

Release Date/Contract Expiration:

Release Date/Contract Expiration:

I certify that I am fully aware of all program and eligibility requirements. I have also read and understand the
contents of the applicable Pre-reporting Guide, including the physical requirements.
Applicant’s Signature:

CGRC-1131 (02/17)

Date:

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OMB Control #: 1625-0128

Expiration Date: 09/30/2021

SECTION IV: COMMENTS AND SIGNATURES
ESO Name:

Signature:

Date:

ESO Optional Comments:

I certify that this package is complete, was compiled and filled out in accordance with the applicable CGRC
Officer Application Packages guide. I also certify that the applicant is fully aware of all program and eligibility
requirements.
Recruiter Name:

Signature:

Date:

Recruiter Optional Comments:

I certify that this package is complete, was compiled and filled out in accordance with the applicable CGRC
Officer Application Packages guide. I also certify that te applicant is fully aware of all program and eligibility
requirements.
RIC Name:

Signature:

Date:

RIC Optional Comments:

CGRC-1131 (02/17)

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OMB Control #: 1625-0128

Expiration Date: 09/30/2021

OFFICER PROGRAM APPLICATION INSTRUCTIONS
Include one (1) copy of pages 1 and 2 of this application form in the package as the first documents on the right side of
the folder. See the applicable program checksheet and its instructions to determine how the rest of the package must be
arranged. Do not include a copy of the application instructions (pages 3-4). Applicants, recruiters and RIC’s
shall sign this application prior to submission. All signatures must be in blue ink.
SECTION I: PERSONAL INFORMATION
Item 1: Enter title/rate/rank and full last name, first name, and middle initial (e.g. AMT1 Smith Jr., John R. or Mr. Smith Jr., John R.).
Item 2: Enter applicant’s date of birth (MM/DD/YYYY).
Items 3-5: Choose from the drop down list the applicant’s gender, race and ethnic category.
Item 6: Enter applicant’s social security number (e.g. 123-45-6789).
Item 7: Enter applicant’s employee identification number (if applicant is a current CG member).
Item 8: Choose ‘Yes’ from the drop down list if the applicant is a U.S. citizen. Choose ‘No’ if the applicant is not.
Item 9: Choose the applicant’s marital status from the drop down list. If the applicant is single, and has sole, legal, or physical custody
of a dependent, see the recruiter for additional submission requirements.
Item 10: Choose from the drop down list the number of dependents. This number MUST include the applicant’s spouse, if married. This
number should account for how many people the applicant has custodial/financial responsibility for (e.g. spouse, children,
parents, siblings, etc.).
Item 11: Enter the recruiting office that the applicant is using to submit this application.
Item 12: Enter the rate/rank, last name, and first name of the applicant’s recruiter (e.g. MST1 Coastie, Robert).
Item 13: Choose from the drop down list the program the applicant is applying for.
Item 14: Choose ‘Yes’ from the drop down list if the applicant is an Active Duty or Reserve (not IRR) Coast Guard member. Choose
‘No’ if the applicant is a CG IRR member, civilian, or member of another branch of the U.S. military.
Item 15: Choose from the drop down list the type of commission being applyed for. A ‘Temporary’ commission requires that the
member be currently serving on active duty orders as an E-5 or above (by panel convening date) and have at least 4 years of
active duty military service (2 years of the active duty military service must have been served in the Coast Guard) no later than
the first published class convening date. Those applicants that are eligible for a temporary commission are not eligible for
a reserve commission.
Item 16: Enter applicant’s current CG unit (if applicant is a current CG member).
Item 17: Enter applicant’s current ESO (if applicant is a current CG member).
Items 18-21: Enter applicant’s home mailing address.
Item 22: Enter a personal email address by which the applicant can be reached.
Items 23-24: Enter applicant’s primary and secondary phone numbers (include country code for non-U.S. numbers). Item 25: Enter
a secondary email if available.
Items 26-30: If the applicant’s address and/or phone number(s) will change in the next six months, enter the
anticipated contact information.

SECTION II: EDUCATION
Item 31: Enter the name of college where the applicant was awarded their qualifying undergraduate degree or the college where the
applicant is currently attending as an undergraduate.
Item 32: Enter the awarded/anticipated degree (e.g. AA, BA, BS, etc.).
Item 33: Enter the major of the awarded/anticipated degree (e.g. Biology, Mathematics, Psychology, etc.).
Item 34: Enter the applicant’s cumulative (CUM) grade point average (GPA) reported by the degree granting institution via the
required memorandum/letter (see applicable program checksheet).
Item 35: Enter the date the applicant’s degree was awarded or the date the applicant anticipates the listed degree being
awarded.
Item 36: Applicant’s that have not yet acquired their degree (based on requirements set for their particular program) should list the
total number of college semester hours completed.
Item 37-39: Enter the applicant’s college information for students applying for a program that allows them to transfer in
accordance with the instructions listed for items 32-34.
Item 40: If the program the applicant is applying for requires a qualifying test , enter the applicant’s qualifying test type (ACT, SAT, or
ASVAB) and score. Qualifying Scores: ACT = Composite score of 23 or greater; SAT (prior to 1 April 1995) = Combined
score of 1000 or greater; SAT I (1 April 1995 to 31 March 2005) = Combined score of 1100 or greater; SAT (after 31 March
2005) = Combined score of 1100 or greater; derived by adding the critical reading (verbal) and math sections. ASVAB GT
Score =109 (derived by combining the AR and VE scores).
Item 41: If the applicant is a part of the Auxiliary University Program (AUP), please select the applicant’s current status in the
program.
Items 42-46: Enter the applicant’s college information for any graduate level degree awarded/anticipated in accordance with the
instructions listed for items 32-36.

CGRC-1131 (02/17)

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OMB Control #: 1625-0128

Expiration Date: 09/30/2021

SECTION III: MILITARY SERVICE
Items 47-48: Enter the applicant’s total active duty and/or reserve time served. Please see applicable program requirements to
determine total time served.
Item 49: Enter applicant’s total military flight time in a manned aircraft as of the application deadline date. Flight hours in training,
simulators, or UAs will not count toward this total.
Items 50-51b: If the applicant is currently serving in a branch of the military, use Item 51a to select the branch the applicant is serving in;
whether the applicant is currently an officer or enlisted member; choose the applicant’s status (Active/Reserve); enter the
applicant’s date of entry; and enter the applicant’s anticipated termination date of his/her current contract. Use Items 51b and
51c to list any previous military service.

SECTION IV: COMMENTS AND SIGNATURES
ESO of current CG members may sign and leave optional comments in this section. Recruiters and RICs must verify
that the entire package is complete in accordance with the applicable CGRC Officer Program Application Packages
guide and the applicant is eligible for the specific officer program by signing and dating the application. Recruiter and
RIC comments are optional. If provided, comments shall be specific and relate to the Recruiter/RIC’s experience with
the applicant. Comments shall not include information related to the applicant’s medical situation.
ADDITIONAL INSTRUCTIONS
Include one (1) copy of pages 1 and 2 of this application form in the package as the first documents on the right side of the
folder. See the applicable program checksheet and its instructions to determine how the rest of the package must be
arranged. Do not include a copy of the application instructions (pages 3-4). Applicants must sign this application
at the bottom of page 1. Recruiters and RICs shall sign this application on page 2. The applicant’s signature
certifies that the applicable Pre-reporting Guide has been read. See the applicable program checksheet and instructions for
details. The lastest version of all program checksheets can be found on www.gocoastguard.com. All signatures must be in blue
ink.
REFERENCES
Officer Accessions, Evaluations, & Promotions Manual (COMDTINST M1000.3)
Coast Guard Recruiting Manual (COMDTINST M1100.2 (series))
CGRC Recruiting Standard Operating Procedure (SOP)
Officer Application Job Aid Kit (O-JAK)

CGRC-1131 (02/17)

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