Marine Corps Screening Form
Congratulations, on taking the first step to see if you’re basically qualified to become a Marine. (Please complete the survey to the best of your ability.)
Full Name
*
First Name
Last Name
Phone Number
*
Select your Birth Date
*
-
Month
-
Day
Year
Date
E-mail
Back
Next
Current City, State
*
ex. Victor, New York
Please select your Gender
*
Female
Male
Are you a High School graduate with a standard diploma or a current high-school student?
*
Graduated High School
Did not Graduate High School
Still in High School
Are you currently attending college?
Yes
No
If Yes, what school
ex. Portland Community College, University of Oregon
Place of Birth
*
Ex. Victor, New York
Back
Next
Height
*
ex. 5'7 or 67 inches
Weight
*
ex. 185
Last Time of Marijuana Usage
*
Please Select
None
1-30 Days
30-90 Days
90-180 Days
180+ Days
Any other drug usage?
*
Yes
No
If yes, what type and last usage?
Police Involvement to include tickets or juvenile record
*
Yes
No
If yes, explain (open or closed)
Back
Next
Medical History (Current or past history of)
*
Surgeries / Operations
Self-Harm
Vision/Glasses
Implants (pins, plates)
Broken Bones
Asthma/Inhaler Usage
Medication Usage (ADHD, Depression, Anxiety)
ER Visits
Skin (ex. Eczema)
Counseling
No medical issues
Other
If you answered yes to any of the above questions, please explain below: (if you have no medical issues put None.)
*
List any extracurricular activities you are involved in.
ex. Sports, volunteer work, hobbies
Back
Next
What would interest you about the Marine Corps? (Choose 3 Options)
Challenge
Self-Direction, Self- Discipline, and Self Reliance
Leadership and Management Skills
Financial Security and Benefits
Technical Skills
Professional Development
Education Benefits
Travel and Adventure
Physical Fitness
Pride of Belonging
Courage, Poise, Self-Confidence
Patriotism
After Submission of this Survey you will be re-directed to the Marine Recruiter in your area.
Submit
Should be Empty: