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APPLICATION 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

10 USC 672(d) and USC 275.

AUTHORITY:

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 duty

DISCLOSURE:

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)

IMCOM G9

All Army Sports

Fort Sam Houston, TX 78234-7588

2. NAME (Last, First, MI)

FULL NAME (L,F,MI) (000-00-000) SSN

3a. PERMANENT HOME ADDRESS (Include ZIP Code)

4a. ADDRESS FROM WHICH YOU WILL REPORT FOR DUTY (If

different from permanent home address) (Include ZIP Code)

YOUR ADDRESS

IMCOM G9

All Army Sports

Fort Sam Houston, TX 78234-7588

3b. HOME TELEPHONE NUMBER (Include area code)

4b. HOME TELEPHONE NUMBER (Include area code)

YOUR PHONE NUMBER

same as 3b

3c. BUSINESS TELEPHONE NUMBER (Include area code)

4c. BUSINESS TELEPHONE NUMBER (Include area code)

YOUR PHONE NUMBER

210-466-1337

WHICH BRANCH?

5. UNIT OF ASSIGNMENT OR ATTACHMENT

6. GRADE

7. BRANCH

All Army Sports/WCAP/AED

YOUR RANK

NG or USAR or IRR

NG, USAR, IRR

8. SEX

9. DOB

10. MARITAL STATUS

11. NO. OF DEPENDENTS

Male

Female

MM-DD-YY

12. PRIMARY SSI (AOC) /MOS

13. DUTY SSI (AOC) /MOS

14. HEIGHT

15. WEIGHT

16.

17. TOTAL YEARS, MONTHS, DAYS OF ACTIVE

FEDERAL SERVICE (AFS)

I am

I am not

drawing a pension, disability compensation,

How many years, months, days

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

Total # of days of

First date of Camp/

same as first choice

Camp/Competitions

Competition

LOCATION

Fort Sam Houston, TX

DUTY/TRAINING AGENCY

leave blank

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

DATE OF LAST PHYSICAL EXAM

WHERE

21. SIGNATURE

22. DATE

MUST BE DATED

YOUR SIGNATURE

PREVIOUS EDITIONS ARE OBSOLETE.

APD PE v1.00ES

DA FORM 1058-R, JUL 2010

Da Form 1058-R - Application 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

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