RIO PIEDRAS RECRUITING STATION

THE AVENGERS
“Whatever It Takes”

APPLICATION INFORMATION
Standard Form 86 Form approved:
Revised September 1995 OMB No. 3206-0007
U.S. Office of Personnel Management NSN 7540-00-634-4036
5 CFR Parts 731, 732, and 736 86-111

(Birth Certificate, Social Security Card, and Diploma, College Transcript; All documents
are to be Originals)

FULL NAME:
ADDRESS:
CITY: ________________ STATE: ZIP:_ Email:
DATE OF BIRTH: PLACE OF BIRTH (CITY/STATE:____________
DRIVERS LICENSE: EXP:
PASSPORT NUMBER: EXP:
HEIGHT: WEIGHT: EYE COLOR: HAIR COLOR:
RELIGIOUS PREF: LAST MENSTRUAL CYCLE:
HOME PHONE #: CELL PHONE #:
MARITAL: SINGLE MARRIED DIVORCED #DEPENDENTS:

**** PRIOR SERVICE ONLY ****

SERVICE: ARMY AIRFORCE NAVY MARINE

SERVICE STATUS: ACTIVE RESERVE
TYPE: OFFICER ENLISTED
RANK:
DATE OF SERVICE: TO
DISCHARGE TYPE: SEPERATION CODE:
RE-CODE: PMOS:
UNIT NAME: ADDRESS:
CITY: STATE: ZIP CODE: _
SUPERVISOR:
RANK:
1

PHONE NUMBER:
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 (ALL NAMES WILL BE COMPLETE: FIRST, MIDDLE, LAST)

DO YOU HAVE ANY: TATOOS? YES NO BODY PIERCINGS? YES NO

BRANDINGS? YES NO IF YES TO ABOVE PLEASE EXPLAIN & LOCATION:

SPOUSE’S INFORMATION:

SPOUSE NAME (MAIDEN NAME) ( )

SOCIAL SECURITY #:
MARRIAGE DATE & CITY/STATE:
DATE OF BIRTH: _/ / ( DD/MMM/YYYY)
PLACE OF BIRTH: (CITY/STATE)
ADDRESS: CITY:
COUNTY: STATE: ZIP:
PHONE #:

FATHER IN LAW: DECEASED (Y/N):___

DATE OF BIRTH: / / ( DD/MMM/YYYY)
ADDRESS: CITY:
COUNTY: STATE: ZIP:
PHONE #:
PLACE OF BIRTH: (CITY/STATE)

MOTHER IN LAW: DECEASED (Y/N):___

DATE OF BIRTH: / / ( DD/MMM/YYYY)
ADDRESS: CITY:
COUNTY: STATE: ZIP:
PHONE #:
PLACE OF BIRTH: (CITY/STATE)

PARENTS INFORMATION: DECEASED (Y/N):___

MOTHER (MAIDEN NAME): ( )
DATE OF BIRTH: / / ( DD/MMM/YYYY)
ADDRESS: CITY:
COUNTY: STATE: ZIP:
PHONE #:
PLACE OF BIRTH: (CITY/STATE)

FATHER: DECEASED (Y/N):___

DATE OF BIRTH: / / ( DD/MMM/YYYY)
ADDRESS: CITY:
COUNTY: STATE: ZIP:
2

PHONE #:
Page

PLACE OF BIRTH: (CITY/STATE)

 (ALL NAMES WILL BE COMPLETE: FIRST, MIDDLE, LAST)

FAMILY MEMBERS: (SON, DAUGHTER, BROTHERS, SISTERS, &

STEP/HALF BROTHERS, SISTERS):
NAME:
DATE OF BIRTH: CITIZENSHIP:
ADDRESS: CITY:
COUNTY: STATE: ZIP:
PHONE #:
PLACE OF BIRTH: (CITY/STATE)
RELATIONSHIP TO YOU:

NAME:
DATE OF BIRTH: CITIZENSHIP:
ADDRESS: CITY:
COUNTY: STATE: ZIP:
PHONE #:
PLACE OF BIRTH: (CITY/STATE)
RELATIONSHIP TO YOU:

NAME:
DATE OF BIRTH: CITIZENSHIP:
ADDRESS: CITY:
COUNTY: STATE: ZIP:
PHONE #:
PLACE OF BIRTH: (CITY/STATE)
RELATIONSHIP TO YOU:

NAME:
DATE OF BIRTH: CITIZENSHIP:
ADDRESS: CITY:
COUNTY: STATE: ZIP:
PHONE #:
PLACE OF BIRTH: (CITY/STATE)
RELATIONSHIP TO YOU:

NAME:
DATE OF BIRTH: CITIZENSHIP:
ADDRESS: CITY:
COUNTY: STATE: ZIP:
PHONE #:
3

PLACE OF BIRTH: (CITY/STATE)

Page

RELATIONSHIP TO YOU:
(ALL NAMES WILL BE COMPLETE: FIRST, MIDDLE, LAST)

WHERE YOU HAVE LIVED THE PAST 10 YEARS:

1) ADDRESS:
CITY: _STATE: ZIP:
FROM: / / TO: PRESENT
( DD/MMM/YYYY)
*SOMEONE WHO KNEW YOU AT THIS ADDRESS*:
LAST NAME: FIRST NAME:
MIDDLE NAME
ADDRESS:
CITY: STATE: ZIP:
PHONE #:

2) ADDRESS:
CITY: _STATE: ZIP:
FROM: / / TO: / /
( DD/MMM/YYYY) ( DD/MMM/YYYY)
*SOMEONE WHO KNEW YOU AT THIS ADDRESS*:
LAST NAME: FIRST NAME:
MIDDLE NAME
ADDRESS:
CITY: STATE: ZIP:
PHONE #:

3) ADDRESS:
CITY: _STATE: ZIP:
FROM: / / TO: / /
( DD/MMM/YYYY) ( DD/MMM/YYYY)
*SOMEONE WHO KNEW YOU AT THIS ADDRESS*:
LAST NAME: FIRST NAME:
MIDDLE NAME
ADDRESS:
CITY: STATE: ZIP:
PHONE #:

4) ADDRESS:
CITY: _STATE: ZIP:
FROM: / / TO: / /
( DD/MMM/YYYY) ( DD/MMM/YYYY)
*SOMEONE WHO KNEW YOU AT THIS ADDRESS*:
LAST NAME: FIRST NAME:
MIDDLE NAME
4

ADDRESS:
Page

CITY: STATE: ZIP:

PHONE #:
 (ALL NAMES WILL BE COMPLETE: FIRST, MIDDLE, LAST)

EDUCATION INFORMATION:

NAME OF HIGH SCHOOL:

ADDRESS:
CITY: _ STATE: ZIP:
ATTENDED FROM: TO: GRAD: YES / NO
(MMM/YYYY) (MMM/YYYY)
PHONE: CONCENTRATION:______________________
*TEACHER, PROFESOR, DIRECTOR, PROGRAM DIRECTOR THAT KNEW YOU
IN SCHOOL*
NAME(LAST, NAME):

NAME OF COLLEGE:
ADDRESS:
CITY: _ STATE: ZIP:
TOTAL CREDITS: ATTENDED FROM:
TO: GRAD: YES / NO
(MMM/YYYY) (MMM/YYYY)
PHONE: CONCENTRATION:
*TEACHER, PROFESOR, DIRECTOR, PROGRAM DIRECTOR THAT KNEW YOU
IN SCHOOL*
NAME(LAST, NAME):

NAME OF SCHOOL: _
ADDRESS:
CITY: _ STATE: ZIP:
TOTAL CREDITS: ATTENDED FROM:
TO: GRAD: YES / NO
(MMM/YYYY) (MMM/YYYY)
PHONE:
*TEACHER, PROFESOR, DIRECTOR, PROGRAM DIRECTOR THAT KNEW YOU
IN SCHOOL*
NAME(LAST, NAME):
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EMPLOYMENT INFORMATION: (PRESENT & PREVIOUS EMPLOYER FOR
THE PAST 10 YEARS)

NAME OF BUSINESS: POSITION:

ADDRESS: PART TIME /FULL TIME
CITY: _ STATE: ZIP:_
HOUR WEEKLY WORKED: PHONE:
POSITION:
SUPERVISOR(FULL NAME):
DATES OF EMPLOYMENT: / / TO: / /
( DD/MMM/YYYY) PRESENT �

NAME OF BUSINESS: POSITION:

ADDRESS: PART TIME / FULL TIME
CITY: _ STATE: ZIP:_
HOUR WEEKLY WORKED: PHONE:
POSITION:
SUPERVISOR(FULL NAME):
DATES OF EMPLOYMENT: / / TO: / /
( DD/MMM/YYYY) PRESENT �

NAME OF BUSINESS: POSITION:

ADDRESS: PART TIME / FULL TIME
CITY: _ STATE: ZIP:_
HOUR WEEKLY WORKED: PHONE:
POSITION:
SUPERVISOR(FULL NAME):
DATES OF EMPLOYMENT: / / TO: / /
( DD/MMM/YYYY) PRESENT �
NAME OF BUSINESS: POSITION:
ADDRESS: PART TIME / FULL TIME
CITY: _ STATE: ZIP:_
HOUR WEEKLY WORKED: PHONE:
POSITION:
SUPERVISOR(FULL NAME):
DATES OF EMPLOYMENT: / / TO: / /
( DD/MMM/YYYY) PRESENT �

NAME OF BUSINESS: POSITION:

ADDRESS: PART TIME / FULL TIME
CITY: _ STATE: ZIP:_
HOUR WEEKLY WORKED: PHONE:
POSITION:
6

SUPERVISOR(FULL NAME):
Page

DATES OF EMPLOYMENT: / / TO: / /

( DD/MMM/YYYY) PRESENT �
 (ALL NAMES WILL BE COMPLETE: FIRST, MIDDLE, LAST)

PERSONAL REFERENCES: ATLEAST 10YRS (NON-FAMILY MEMBERS)

*** WELL-KNOWN REFERENCES & THEY WILL BE CONTACTED ***

RELATIONSHIP: FRIEND NEIGHBOR OTHER SCHOOLMATE WORK ASSOCIATE

LAST NAME: FIRST NAME:

MIDDLE NAME:
PHONE #:
ADDRESS: CITY:
STATE: ZIP:
I KNOW THIS PERSON SINCE: / / ( DD/MMM/YYYY)
LAST DAY CONTACTED:

RELATIONSHIP: FRIEND NEIGHBOR OTHER SCHOOLMATE WORK ASSOCIATE

LAST NAME: FIRST NAME:

MIDDLE NAME:
PHONE #:
ADDRESS: CITY:
STATE: ZIP:
I KNOW THIS PERSON SINCE: / / ( DD/MMM/YYYY)
LAST DAY CONTACTED:

RELATIONSHIP: FRIEND NEIGHBOR OTHER SCHOOLMATE WORK ASSOCIATE

LAST NAME: FIRST NAME:

MIDDLE NAME:
PHONE #:
ADDRESS: CITY:
STATE: ZIP:
I KNOW THIS PERSON SINCE: / / ( DD/MMM/YYYY)
LAST DAY CONTACTED:
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MEDICAL HISTORY

ALLERGIES: YES / NO (IF YES EXPLAIN)

SURGERY: YES / NO (IF YES EXPLAIN)

ANY TYPE OF MEDICAL PROCEDURE: YES / NO (IF YES EXPLAIN)

CURRENTLY ON ANY MEDICATION: YES / NO (IF YES EXPLAIN)

LAW VIOLATIONS:

ARRESTED: YES / NO (IF YES EXPLAIN)

TRAFFIC TICKETS: YES / NO (IF YES EXPLAIN)

IF YES TO TRAFFIC TICKETS, ARE THOSE TICKETS STILL UNPAID?: YES / NO

(IF YES EXPLAIN)

COURT CITATION: YES / NO (IF YES EXPLAIN)

ANY TYPE OF DOMESTIC VIOLENCE OR DISPUTE: YES / NO (IF YES

EXPLAIN)
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ANY TYPE OF ISSUE WITH LAW OR COURT: YES / NO (IF YES EXPLAIN)
 HAVE YOU EVER HAD ANY TICKETS? (PAID OR NOT) YES / NO

IF YES;

WHEN? (DATE) WHAT CITY, STATE? WHY WAS THE TICKET HOW MUCH YOU
(DD/MMM/YYYY) FOR? PAID?
/ / $
ESTIMATE
/ / $
ESTIMATE
/ / $
ESTIMATE
/ / $
ESTIMATE
/ / $
ESTIMATE
/ / $
ESTIMATE
/ / $
ESTIMATE
/ / $
ESTIMATE
/ / $
ESTIMATE
/ / $
ESTIMATE
/ / $
ESTIMATE

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FOREIGN LANGUAGE: READ____ SPEAK____ WRITE____ UNDERSTAND___
BANKRUPTCY (CHAPTER 7, 11, 13): NO YES
DEBTS (over 180 DAY): NO YES (currently over 90 DAY): NO YES
PAST LOANS, TAXES, CHILD SUPPORT, COLLECTION AGENCY: NO YES
FOREIGN HISTORY:
HAVE YOU EVER BEEN OUTSIDE OF THE UNITED STATES OR TERRITORIES?
YES / NO

HAVE YOU EVER BEEN ON A CRUISE?

YES / NO

IF YES TO ANY OF THE ABOVE, EXPLAIN:

COUNTRY:
FROM: / / TO: / / ( DD/MMM/YYYY)
PURPOSE OF THE VISIT:

COUNTRY:
FROM: / / TO: / / ( DD/MMM/YYYY)
PURPOSE OF THE VISIT:

COUNTRY:
FROM: / / TO: / / ( DD/MMM/YYYY)
PURPOSE OF THE VISIT:

COUNTRY:
FROM: / / TO: / / ( DD/MMM/YYYY)
PURPOSE OF THE VISIT:

COUNTRY:
FROM: / / TO: / / ( DD/MMM/YYYY)
PURPOSE OF THE VISIT:

COUNTRY:
FROM: / / TO: / / ( DD/MMM/YYYY)
PURPOSE OF THE VISIT:

COUNTRY:
FROM: / / TO: / / ( DD/MMM/YYYY)
PURPOSE OF THE VISIT:

COUNTRY:
FROM: / / TO: / / ( DD/MMM/YYYY)
PURPOSE OF THE VISIT:
COUNTRY:
10

FROM: / / TO: / / ( DD/MMM/YYYY)

PURPOSE OF THE VISIT:
Page

COUNTRY:
FROM: / / TO: / / ( DD/MMM/YYYY)
PURPOSE OF THE VISIT:
 Answer Yes or No

a. Were you ever depressed or down, most of the day, nearly every day for 2 weeks?

b. For the past 2 weeks, were you depressed or down, most of the day, nearly every day?

c. Were you ever much less interested in most things or much less able to enjoy the things you used to
enjoy most of the time for 2 weeks

d. In the past 2 weeks, were you much less interested in most things or much less able to enjoy the things
you used to enjoy, most of the the time?

e. Have you ever deliberatly cut, burned, or injured yourself?

f. Have you ever considered or attempted suicide?

g. Have you ever been arrested?

h. Have you ever been suspended from school?

i. Have you ever been fired from your job?

ii.
j. Have you ever been kicked out of your home?

k. Have you had three or more traffic violations?

l. Have you ever had trouble sleeping nearly every night (difficulty falling asleep, waking up in the middle of the night,
early morning waking or sleeping excessively) for a period of 2 weeks or longer?

a. How often do you have a drink containing alcohol? per week per month
b. How many drinks containing alcohol do you have on a typical day? per week per month
c. How often do you have six or more drinks on one occasion? per week per month
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 NEEDED DOCUMENTS

To continue your processing I will need the following documents. They

must be the original documents or a certified copy with seal.

1. Birth certificate (Original)

2. Social Security Card
3. High School Diploma or Transcript or GED (Original)
4. College Diploma or Transcripts
5. Driver’s License
6. Marriage License/Certificate or Divorce Decree
7. Dependent Id Card / SSN Card / Birth Certificate
8. Other documents needed:

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ADDITIONAL QUESTIONS?
GIVE US A CALL AT (787) 764-7200