VOLUNTEER SERVICE RECORD
For use of this form, see AR 608-1; the proponent agency is OACSIM.
PRIVACY ACT STATEMENT
5 USC Section 301, Department Regulations; 10 USC Section 3013, Secretary of the Army; and Army
Regulation 608-1, Army Community Service Center.
To record essential background information on volunteers to assist in determining qualifications and task
assignments. To maintain record of positions held, hours volunteered, training and awards received.
None. The "Blanket Routine Uses" set forth at the beginning of the Army's Complications of System of
Records Notices apply to this system.
Voluntary. However, failure to provide the requested information may exclude you from participating in the
Army Community Service Volunteer Program.
INSTRUCTIONS: Upon resignation, retirement or transfer, the original of this record will be furnished for the personal file of the volunteer and
a duplicate will be maintained at the organization for at least three years. In case of transfer, a duplicate record will be furnished to the gaining
organization upon request of the volunteer.
1. NAME OF VOLUNTEER (Last, First, MI)
2. HOME ADDRESS (Street, City, State and ZIP Code)
3. EMAIL ADDRESS
4. TELEPHONE NUMBERS
6. DATE OF BIRTH (YYYYMMDD)
7a. SPONSOR NAME
7b. SPONSOR UNIT ADDRESS
8. Mark all the demographic data that applies to the volunteer. Family members of service members should indicate the branch of service and
status of the sponsor.
(APF and NAF)
ADULT FAMILY MEMBER
YOUTH FAMILY MEMBER
(Under age 18 and unmarried)
CIVILIAN (Not connected with
9. CHILDREN AT HOME
10. INITIAL COMMITMENT
ONE DAY EVENT
ONE MONTH EVENT
12. WORK EXPERIENCE
13. VOLUNTEER EXPERIENCE
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DA FORM 4162, JUL 2003
DA FORM 4162, MAY 1999, IS OBSOLETE.