1. I certify that I have read and explained all the conditions and stipulations concerning the specific program set forth above under w hich the individual w ill become a member of an ARMY NATIONAL GUARD unit. Follow ing this reading and explanation, a copy of this signed form w as furnished the above soldier.
a. TYPED NAME OF CAREER COUNSELOR d. SIGNATURE
b. RANK c. TITLE
e. DATE SIGNED (YYYYMMDD) 2. REMARKS
USAPA V1. 00
Figure 11-8 (Page 3). Sample of DA Form 7249-R (Annex A – Certificate of Acknowledgement of Service Requirements)
DOUG PORTS 200-00-0001
Doug Ports 2006 APR 01
THOMPSON MICHAEL MSG RC CAREER COUNSELOR
OATH OF EX TENSION OF ENLISTMENT
For use of this fo rm, see A R 6 0 1 -2 8 0 ; the proponent agency is DCSPER
EXTENSION CONTROL NUMBER
(If applicable)
APPLICANT DATA
AGREEMENT
FULL SIGNATURE OF APPLICANT
RESPONSIBLE CAREER COUNSELOR
ADMINISTERING OFFICER
SIGNATURE
Subscribed to before me this day of .
I, a member of the Regular Army, do hereby acknowledge this voluntarily extended my
as a soldier in the Regular Army of the United States to a period of the last mentioned date. The period of this extension is
My request for extension is Up paragraph
day of , to have
enlistment of the day of ,
years months w eeks from
months and my new ETS date is .
. chapter 4, AR 601-280.
(Enter current enlistment as extended)
(Appropriate paragraph)
DA FORM 169 5, MAY 1998 EDITION OF AUG 86 IS OBSOLETE
NAME (Last First, Middle) RANK SSN
PLACE OF EXTENSION (Unit, Installation, State, ZIP Code)
DATE SIGNED
TYPED NAME (Last, First, MI) RANK CCID UNIT (Unit, Installation, State, ZIP Code)
REMARKS
TYPED NAME (Last, First, MI) RANK
UNIT (Unit, Installation, State, ZIP Code)
(Specify reason)
USAPA V1.00
Figure 11-9. Sample of DA Form 1695 (Oath of Extension)
ROBERTSON ROBERT RAY SGT 000-00-0001
0002 IN DIV 2D INF DIV, APO AP 96224 0000010
11TH SEPTEMBER 2013
4 YEAR 24TH AUGUST 2012
04 07 00
07 03 MARCH 2017
TO MEET THE SRR FOR RECRUITING DUTY
4-9a
ROBERT RAY ROBERTSON
2017 SEP 11ROEBACK WOODROW SFC R-0389 0002 IN DIV 2D INF DIV
APO AP 96224
11TH SEPTEMBER 2013
LOTT, CRAIG T. CPT
OATH OF EX TENSION OF ENLISTMENT
For use of this fo rm, see A R 6 0 1 -2 8 0 ; the proponent agency is DCSPER
EXTENSION CONTROL NUMBER
(If applicable)
APPLICANT DATA
AGREEMENT
FULL SIGNATURE OF APPLICANT
RESPONSIBLE CAREER COUNSELOR
ADMINISTERING OFFICER
SIGNATURE
Subscribed to before me this day of .
I, a member of the Regular Army, do hereby acknowledge this voluntarily extended my
as a soldier in the Regular Army of the United States to a period of the last mentioned date. The period of this extension is
My request for extension is Up paragraph
day of , to have
enlistment of the day of ,
years months w eeks from
months and my new ETS date is .
. chapter 4, AR 601-280.
(Enter current enlistment as extended)
(Appropriate paragraph)
DA FORM 169 5, MAY 1998 EDITION OF AUG 86 IS OBSOLETE
NAME (Last First, Middle) RANK SSN
PLACE OF EXTENSION (Unit, Installation, State, ZIP Code)
DATE SIGNED
TYPED NAME (Last, First, MI) RANK CCID UNIT (Unit, Installation, State, ZIP Code)
REMARKS
TYPED NAME (Last, First, MI) RANK
UNIT (Unit, Installation, State, ZIP Code)
(Specify reason)
USAPA V1.00
Figure 11-10. Sample of DA Form 1695 (Oath of Extension for BEAR Participation)
BEAUPRE MICHAEL SPC 400-00-0004 MONCRIEFARMYCOMMUNITYHOSPITAL, FT JACKSON, SC 29207 0000013 21ST JANUARY 2013 4 YEAR 11TH MAY 2012 06 06 00 30 10 NOVEMBER 2014
TO MEET THE SRR FOR BEAR PROGRAM PARTICIPATION (MOS 88M)
4-9a
Michael Beaupre 2012 JAN 21
FRENCH LORENZO G. III SSG F-0389 MONCRIEF ARMY COMMUNITY HOSPITAL FT JACKSON, SC 29207
APPROVED BEAR MOS 88M BEAR SRB AWARD LEVEL 2.0A
TRAINING COMPLETION DATE 20081103 ANNEX-A ATTACHED MILPER MESSAGE 08-1XX
21ST JANUARY 2012
MOSS MICHAEL CPT
MONCRIEF ARMY COMMUNITY HOSPITAL
10. LETTER(S) OF INDEBTEDNESS
DA TE
5 . WT.
WAIV ER OF DISQUALIFICATION FOR REENLISTMENT/ PROMOTION IN THE REGULAR ARMY
For use of this form see A R 6 0 1 -2 8 0 ; the proponent agency is DCSPER
4 . HT. CODE
1 3 . TYPED NA ME, RA NK AND BRA NCH OF COMMA NDER SIGNA TURE
PA RA GRA PH
TYPE
TO: (Include ZIP Code) FROM: (Include ZIP Code)
3 . P U L H E S DA TE OF PHYSICA L DA TE OF PROFILE
BRIEF SUMMA RY OF A SSIGNMENT LIMITA TIONS
DISQUALIFICATION
6 . SQT DA TA PMOS SCORE DA TE
7. TIME LOST DURING CURRENT SERVICE
DA TES (From/To ) NO. OF DA YS REA SON
OFFENSE
TYPE DA TE OF CONVICTION SENTENCE
OFFENSE
A RTICLE/TYPE DA TE OF CONVICTION SENTENCE
CREDITOR A MOUNT DISPOSITION
1 1 . RECOMMENDA TION OF COMMA NDING OFFICER WITH REA SONS A ND JUSTIFICA TIONS (USE CONTINUATION SHEET PER AR 340-15, IF
1 2 . LIST OF ENCLOSURES (Double column, if necessary)
8. COURTS-MARTIAL DURING CURRENT TERM OF SERVICE
9. ARTICLE 15 DURING CURRENT TERM OF SERVICE
2 . SSN 1 . RA NK/NA ME (Last, Firs t, Middle)
A R 6 01 -2 8 0
PHYSICA L STA TUS
DA TE OF LETTER
REQUIRED)
DA FORM 3072-R, MAY 88 PREV IOUS EDITION OF JA N 8 8 IS OBSOLETE. USAPPC V1. 00
Figure 11-11. Sample of DA Form 3072 (Waiver of Disqualification for Reenlistment/Promotion in the Regular Army) 2011 MAR 21
3-9a(3)
COMMANDER COMMANDER
0003 IN BDE 2D BCT 0003 IN BDE 02 2D BCT AWOL/LOST TIME FT STEWART, GA 31313 FT STEWART, GA 31313
PFC/ROBERTSON, ROBERT RAY 000-00-0001
1 1 1 1 1 1 A 2009 AUG 23 NONE 68 168
NONE
20100902/20100904 3 LOST TIME
NONE
86/CO AWOL 20060919 FORFEIT $50 FOR ONE MONTH
SUSPENDED BUST 3 MONTHS
NONE
PFC ROBERTSON IS NOW A CANDIDATE FOR FURTHER SERVICE. HIS MONTHLY COUNSELING STATEMENTS REFLECT HIS ABILITY TO OVERCOME HIS DEFICIENCY, AND SOLID PERFORMANCE AND POSITIVE ATTITUDE DURING BOTH THE PREDEPLOYMENT AND DEPLOYMENT PHASES. HE RECIEVED A COA FOR HIS PREDEPLOYMENT EFFORTS THAT CONTRIBUTED TO THE UNIT’S MISSION SUCCESS.
2 ENCLS 1. ERB
2. SOLDIER’S STATEMENT
DA FORM 3286, DEC 94 EDITION OF SEP 79 IS OBSOLETE Page 1 of 2
Figure 11-12 (Page 1). Sample of DA Form 3286 (Statement of Enlistment)
STATEMENTS FOR ENLISTMENT
(PARTS I THROUGH IV)
For use of this form, see AR 601-280; the proponent agency is ODCSPER DATA REQUIRED BY THE PRIVACY ACT OF 1974
AUTHORITY: Section 504, 505, 508, and 510, Title 10, USC.
PRINCIPAL PURPOSE: To determine eligibility for reenlistment.
ROUTINE USES: Information may be referred to appropriate authorities if disciplinary action or discharge for fraudulent
enlistment/reenlistment is appropriate.
DISCLOSURE: Disclosure of personal information is voluntary, however, failure to furnish information requested may result in
denial of reenlistment in the US Army.