Fillable Da Form 61 - Application For Appointment

Da Form 61 - Application For Appointment - 1981 Page 3

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APPLICANTS FOR

35.

APPLICANTS FOR JUDGE ADVOCATE GENERAL'S CORPS ONLY

34.

CHAPLAINS BRANCH ONLY

RELIGIOUS DENOMINATION BY

BARS OF WHICH YOU ARE A MEMBER (Specify dates)

WHICH YOU WILL BE ENDORSED

36.

APPLICANTS FOR MEDICAL AND DENTAL CORPS ONLY

a. TRAINING

c. DATES (Month and Year)

b. NAME AND LOCATION OF HOSPITAL

FROM

LEVEL

TYPE

INTERNSHIP

RESIDENCY TNG

SPECIALTY TNG

d. SPECIALTY BOARDS

e. DATES OF CERTIFICATION

(Day, Month, Yr)

f. PLACE IN WHICH CURRENTLY LICENSED

37. APPLICANTS FOR ARMY NURSE CORPS AND ARMY MEDICAL SPECIALIST CORPS ONLY

a. NAME OF NURSING OR ACCREDITED PROFESSIONAL SCHOOL

b. LOCATION

d. STATE AND CURRENT REGISTRATION NUMBER

STATE AND DATE OF INITIAL

c. DATES OF ATTENDANCE

(Mo, Yr)

REGISTRATION (Day, Month, Year)

FROM

f. POSTGRADUATE COURSES (Include courses at general hospitals, service schools, and short courses)

(1)

(2)

(3)

SEMESTER

DATES OF ATTENDANCE (Month, Year)

CREDITS

SUBJECT OR COURSE

NAME AND LOCATION OF SCHOOL OR HOSPITAL

EARNED

FROM

38. HAVE YOU BEEN EMPLOYED BY THE US ARMY AS A DIETITIAN, OCCUPATIONAL OR PHYSICAL THERAPIST?

(If yes, give dates)

YES

39.

ARMY ROTC (To be completed only by prospective ROTC graduates applying for appointment in USAR or RA)

SUCCESSFULLY COMPLETED AROTC PROGRAM AS FOLLOWS

DATES ATTENDED (Month and Year)

c. CAMP TRAINING

COURSE

FROM

(1) INSTALLATION (Basic)

COMPLETION DATE (Month, Year)

a. BASIC

(2) INSTALLATION (Advanced/Ranger)

COMPLETION DATE (Month, Year)

b. ADVANCED

40. MAIN CIVILIAN EMPLOYMENT

a. NAME AND ADDRESS OF EMPLOYER

b. JOB TITLE

c. MONTH AND YEAR

FROM

b. PRINCIPAL DUTIES (Describe briefly)

41. REMARKS (Experience, proficiencies and special abilities not shown elsewhere in this application. Those required to enter primary entry specialties, see Para 1-27d,e, AR 601-100). (If more

space is required, attach additional sheet)

DATE

SIGNATURE OF APPLICANT

42. THE INFORMATION CONTAINED HEREIN IS TRUE

TO THE BEST OF MY KNOWLEDGE AND BELIEF.

APD LC v2.01ES