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Today's Date

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Date
Due to the increasing demands for high quality men and women in the United States Navy, we would appreciate your cooperation in answering the questions below and returning this form to your recruiter. Only a few moments of your time will be required.
Name
Birthdate

MonthDayYear
Date
Address
City & State
Zip Code
Phone (Home)
(Cell)
Email address
example@example.com
Name of your School
Highest level of education completed or current grade
Estimate of your current height and weight:
Height
Weight
What is the highest level of math you have taken in school? (ie., Geom, ALG I, II, Trig)
Do you know anyone who has joined the Navy?
Have you heard of the Navy’s guaranteed job?
Which of the following might influence you to join the Navy?

EducationJob trainingFree dental careFree medical caretravelChallengeassured pay20 year retirementjob securityadvancement/promotion college credit for youexperience/trainingNavy college fund100% Tuition Assistancehome/business loans
Which of the following occupational fields interest you?

ElectronicsConstructionAdministrationFirefightingaviationnuclear poweraccountingcommunicationweldingfinancejournalismmedica/dentalengineeringsubmarinesphotographycomputers
Would you be willing to make an investment of 30 minutes of your time to discuss opportunities available to you in the Navy?If no, your reason(s) would be most helpful:

YesNo
No
Thank you for your time. If there is anything I can do for you, please give me a call at:

NRS address: 1902 N. Campus Ave, Upland, CA 91784 PRIVACY ACT NOTICE: The enclosed document may contain information covered under the Privacy act of 1974, 5 USC 552a and its various implementing regulations and must be protected in accordance with those provisions. You, the recipient, are obligated to maintain it in: asafe, secure, and confidential manner. Re-disclosure without additional consent or as permitted by law is prohibited. Unauthorized re-disclosure or failure to maintain confidentiality subjects you to application of appropriate sanctions. If you have received this correspondence in error, please notify the NIS at once and destroy any copies you have made.
NRS Rancho Cucamonga

1902 N Campus Ave, suite E

Upland, CA, 91784

office: (909)958-8951

EMN1 Anderson cell: (909)985-8951
Should be Empty: