Air National Guard Pre- Qual Questionnaire
Have you talked to another recruiter in the past?
Yes
No
If "yes" what is the name of the recruiter and 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? if "yes", which branch?
Name
*
First Name
Last Name
Gender:
Male
Female
Other
Current Age:
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Birthplace
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
Divorce
Widow
How Many Kids do you have (under age of 18)?
Current Height
*
(inches ex 5'10" = 70")
Current Weight:
*
(Pounds)
Valid Drivers License or State ID?
Yes
No
Racial Background: ( mark all that apply)
American Indiana/ Alaskan Native
Asian
Black
Native Hawaiian or Pacific Islander
White
Ethnic Background
Hispanic / Latino
Non Hispanic/ Latino
Hair color:
Please Select
Black
Eye Color:
Please Select
Blue
Brown
Green
Gray
Other
Religious Preference:
Highest level of Education:
GED
High School Graduate
Some College
Associates Degree
Bachelors Degree
High School Junior
High School Senior
Home School Graduate
Masters Degree
PHD
Name of High School
Month and Year of High School Graduation:
Name of College: (if applicable)
Do you have or have you ever had any of the follow:(mark all that apply)
Asthma
Respiratory Problems
Allergies
Inhaler Use
Broken Bones
Plates/Pins/Screws
Hospitalizations
Surgery(s)
Allergic Reactions to Foods/ Drugs/ Animals/ Insects/ Other
Missing Appendages
Skin Rashes/ Eczema/ Acne
Glasses
Braces
Hearing Aids
Orthotics
None of the Above
Please explain any Marked Answers Above:
Have you ever taken or are you currently taking any medications prescribed by a doctor? What Medications and When?
Are/ 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 any other mental disorder? if so, what medication and when?
Females Only: Are you currently pregnant?
Yes
No
Have you ever used, possessed, sold or transported any illegal drugs to include marijuana?
Yes
No
Types of drug(s) used, total number of times and dates lasted used:
Have you ever been Charged, arrested, cited (including moving violations/ speeding tickets). held or questioned by any law enforcement agency?
Yes
No
If answered "Yes" for above, please give an explanation for the occurrence:
Do you have any fines that have not been paid (to include: speeding/ parking/moving violations)?
Yes
No
Which Recruiter did you have contact with?
*
TSgt Lopez Castro
TSgt Hozian
TSgt Leito
SSgt Weathers
SSgt Cirwithian
Other
I affirm that all the information provided is true and accurate to the best of my knowledge
*
Submit
Submit
Should be Empty: