Enlistment Qualification Screening

United States Marine Corps Enlistment Eligibility Screening Team, Ames

Qualification Screening Form
Thank you for taking the time to complete our applicant screening form. The information provided will be used to evaluate your eligibility and competitiveness for becoming a Marine. Once submitted, a Marine Corps Representative will contact you to inform you of the options available to you.
Full Name*

First NameMiddle NameLast Name
E-mail
example@example.com (needed for confirmation)
Address*

Street Address

County

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Highest Grade Completed*
Name of School
ex: Example High School/University
Number of College Credits*
Yes - By BirthYes - Naturalized CitizenYes - But I have Dual CitizenshipNo - Not a Citizen
Place of Birth*
City, State
Date of Birth*
YYYY/MM/DD
Current Height and Weight*

Rows Height (in) Weight (lbs)
Gender*
Have you ever had asthma or used an inhaler? *
Have you ever had any kind of implant? *
Ex. Tubes in ears as a kid. (foreign object that you were not born with, emplaced for function)
Are you currently on any long term medication?*
ADHD meds, ect.
Do you have any prolonged medical conditions or diseases?*
Have you ever worn, or needed to wear contacts/glasses to correct vision?*
Have you ever been hospitalized or had any surgeries?*
(Briefly Explain)
Do you have any Adverse Reactions to; Medications, Materials, or Insect Stings?*
(Briefly Explain)
Have you ever broken any bones?*
(Briefly Explain)
Have you had any head injuries, concussions, or lost consciousness?*
(Briefly Explain)
Have you ever recieved counseling or psychiatric treatment?*
(Briefly Explain)
Do you have any tattoos? If so, what are they, and where are they?*
(Briefly Explain)
Do you have piercings? If so, how many, and where?*
(Briefly Explain)
Have you ever received any type of ticket from law enforcement? What kind and when?*
(Briefly Explain)
Have you ever used illegal drugs? If so, what kind, how many times, and when was the last time used?*
(Briefly Explain)
Have you or your family ever served in the Military?*
SingleMarriedSeparatedDivorcedOther
Do you have children? If yes, how many?*
(Briefly Explain)
Courage, Poise, Self-ConfidenceChallengeFinancial Security, Advancement & BenefitsPhysical FitnessLeadership, Management SkillsSelf Reliance, Discipline, DirectionProfessional DevelopmentTravel & AdventureEducational OpportunityPride of BelongingTechnical Skills
Yes - I want to learn about the MarinesNo - I don't want extra opportunitiesMaybe
Should be Empty:

Rows	Height (in)	Weight (lbs)

United States Marine Corps Enlistment Eligibility Screening Team, Ames