Da Form 1696 - Vaccine Consent And Assessment Form Page 2
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210.
CIVILIAN EDUCATION
LEVEL
NAME AND LOCATION OF SCHOOL
MAJOR OR SPECIALITY
DEGREE
YEAR
HIGH SCHOOL
COLLEGE
UNIVERSITY
POST GRADUATE
OTHER EDUCATION AND DESCRIPTION OF TRAINING WHICH QUALIFIES FOR ENLISTMENT/REENLISTMENT SPECIFIED
11.
CIVILIAN EMPLOYMENT SINCE DATE OF LAST SEPARATION FROM THE ARMED FORCES
(If additional space is required, use additional sheet of paper)
FROM (Date)
TO (Date)
EMPLOYER AND ADDRESS
DESCRIPTION OF DUTIES AND RESPONSIBILITIES
FROM (Date)
TO (Date)
EMPLOYER AND ADDRESS
DESCRIPTION OF DUTIES AND RESPONSIBILITIES
12. LIST OF SUPPORTING DOCUMENTS (Attached)
13.
STATEMENT OF APPLICANT
I,
, DO HEREBY ACKNOWLEDGE THAT I HAVE EXAMINED IN DETAIL THE DATA AND
INFORMATION PRESENTED HEREIN AND THAT THE SAME ARE TRUE, COMPLETE AND CORRECT TO THE BEST OF MY
KNOWLEDGE AND BELIEF.
14. RECOMMENDATIONS OF RECRUITING OFFICER TO INCLUDE MOS AND GRADE;
TYPED NAME, GRADE, AND ORGANIZATION OF RECRUITING OFFICER
SIGNATURE
DA FORM 1696, APR 2005
Page 2 of 2
APD LC v1.01ES
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