Da Form 1058-R Application For Active Duty For Training, Active Duty For Special Work
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1
2APPLICATION FOR ACTIVE DUTY FOR TRAINING, ACTIVE DUTY FOR SPECIAL WORK,
TEMPORARY TOUR OF ACTIVE DUTY, AND ANNUAL TRAINING FOR SOLDIERS OF THE
ARMY NATIONAL GUARD AND U.S. ARMY RESERVE
For use of this form, see AR 135-200; the proponent agency is DCS, G-1.
DATA REQUIRED BY THE PRIVACY ACT OF 1974
AUTHORITY:
10 USC 672(d) and USC 275.
To determine eligibility and schedule individuals for active duty for special work or active duty for training
PRINCIPAL PURPOSE:
on requested dates.
To identify the applicant as a Reserve Component member and to issue active duty for special work or
ROUTINE USES:
active duty for training orders.
Completing this form is mandatory for individuals applying for active duty for special work and active
DISCLOSURE:
duty for training. If not completed, you will be ineligible for the requested tour.
PART I - APPLICANT (Read instructions in AR 135-200 before completing this form.)
1. TO (Include ZIP Code)
2. NAME (Last, First, MI)
4a. ADDRESS FROM WHICH YOU WILL REPORT FOR DUTY (If
3a. PERMANENT HOME ADDRESS (Include ZIP Code)
different from permanent home address) (Include ZIP Code)
3b. HOME TELEPHONE NUMBER (Include area code)
4b. HOME TELEPHONE NUMBER (Include area code)
3c. BUSINESS TELEPHONE NUMBER (Include area code)
4c. BUSINESS TELEPHONE NUMBER (Include area code)
5. UNIT OF ASSIGNMENT OR ATTACHMENT
6. GRADE
7. BRANCH
8. SEX
9. DOB
10. MARITAL STATUS
11. NO. OF DEPENDENTS
Male
Female
13. DUTY SSI (AOC) /MOS
12. PRIMARY SSI (AOC) /MOS
14. HEIGHT
15. WEIGHT
17. TOTAL YEARS, MONTHS, DAYS OF
16.
ACTIVE FEDERAL SERVICE (AFS)
drawing a pension, disability compensation,
I am
I am not
or retired pay from the U.S. Government.
18. FOR INDIVIDUAL MOBILIZATION AUGMENTEES ONLY: THIS APPLICATION IS FOR (Check one)
IMA AT
ADT in lieu of IMA AT
Additional ADT
19. DATES OF ADSW/TTAD/ADT/AT REQUESTED
a. FIRST CHOICE
b. SECOND CHOICE
NUMBER OF DAYS
BEGINNING DATE/TIME
NUMBER OF DAYS
BEGINNING DATE/TIME
LOCATION
LOCATION
DUTY/TRAINING AGENCY
DUTY/TRAINING AGENCY
20. To the best of my knowledge and belief, I am physically qualified for active military duty. I was
a. LAST EXAMINED ON
b. AT
21. SIGNATURE
22. DATE
APD LC v1.00ES
PREVIOUS EDITIONS ARE OBSOLETE.
DA FORM 1058-R, JUL 2010
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