Air National Guard Pre-Qual Questionnaire
Have you talked to another recruiter in the past year?
Yes
No
If you answered the above question as "yes" what is the name of the recruiter and the branch of service?
Have you ever taken the ASVAB?
Yes
No
Have you ever taken an enlistment physical?
Yes
No
Have you ever served in any branch of the military previously? If yes, which branch?
Name:
First Name
Middle Name
Last Name
Suffix
Gender:
Male
Female
Current Age:
Cell Phone Number:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email:
Birthplace:
(City and State)
Are you a citizen of the United States?
Yes
No
Marital Status:
Please Select
Single
Married to civilian
Married to another military member
Legally separated
Divorced
How many kids do you have (under the age of 18)?
Current Height:
(inches)
Current Weight:
(pounds)
Valid Drivers License or State ID?
Yes
No
Racial Background: (mark all that apply)
American Indian/Alaskan Native
Asian
Black
Native Hawaiian or Pacific Islander
White
Ethnic Background:
Hispanic/Latino
Not Hispanic/Latino
Hair Color:
Please Select
Black
Blonde
Brown
Gray
Red
None-Bald
Eye Color:
Please Select
Blue
Brown
Gray
Green
Other
Religious Preference:
Highest Level of Education:
High School Graduate
Some College
Associates Degree
Bachelors Degree
High School Junior
High School Senior
GED
Home School Graduate
Name of High School:
Month and Year of High School Graduation:
Name of College: (if applicable)
Do you now have or have you ever had any of the following: (mark all that apply)
Asthma
Respiratory Problems
Allergies
Inhaler Use
Broken Bones
Pins/Screws/Plates
Hospitalizations
Surgery(s)
Tattoos
Piercings
Allergic Reactions to foods/drugs/animals/insects/other
Missing Appendages
Skin Rashes/Eczema/Acne
Glasses
Braces
Hearing Aids
Orthotics
None of the above
Explain any Marked Answers Above:
Have you ever taken or are you currently taking any medications prescribed by a doctor? What Medications?
Have you ever seen a counselor or therapist? If so what type of counseling?
Have you ever been diagnosed by a doctor, with any of the following mental disorders? (mark all that apply)
Stress
ADD
ADHD
Depression
Attempted Suicide
Anxiety
None of the above
Have you ever been prescribed medication for anxiety, depression or any other mental disorder? If so, what medication?
Females Only: Are you currently pregnant?
Yes
No
Have you ever used, possessed, sold or transported any illegal drugs to include marijuana, even if it was one time or for experimental use?
Yes
No
Type of drug(s) used, total number of times and date last used:
Have you ever been charged, arrested, cited, held or questioned by any law enforcement agency?
Yes
No
If the above question was answered as "yes" give an explanation for the occurence:
Do you have any fines that have not been paid?
Yes
No
I affirm that all the information provided is true and accurate to the best of my knowledge.
Yes
No
Submit
Should be Empty: