Job (e.g., Rifleman, Security) Have you ever been subject to court martial or any other disciplinary proceeding under the Uniform Code of Military Justice? (Include non-judicial, Captain's mast, etc.) If "Yes," provide date(s), charge(s), military court(s) or authority(ies), and outcome(s). _________________________________________________________________________________________________ SPECIAL QUALIFICATIONS & SKILLS Identify any special licenses you hold (e.g., radio operator): If you know a foreign language, indicate your fluency in each block below(excellent, good, fair) Language Understanding Speaking Reading Writing Do you have any experience with firearms? Yes No MEMBERSHIP IN ORGANIZATIONS (PAST AND PRESENT) Name & Address Type (e.g., social, fraternal, professional) From To Have you ever been an officer or a member of, or made a contribution to, an organization that advocates or practices the commission of acts of or violence to discourage others from exercising their rights under the U.S. Constitution or right granted by law. Yes_______ No_______ PERSONAL DECLARATIONS Do you consume alcoholic beverages? Yes No If how often? _________________ “Yes”, Have you ever used marijuana or hashish? Yes No If yes, when last used? Have you ever used any illegal drug (including a performance-enhancing steroid) not prescribed by a physician? Yes No If yes how often___________ When last used______________ Provide explanation: Have you ever sold or furnished controlled substances or prescription drugs to anyone? Yes No If yes, give details:
Job (e.g., Rifleman, Security) Have you ever been subject to court martial or any other disciplinary proceeding under the Uniform Code of Military Justice? (Include non-judicial, Captain's mast, etc.) If "Yes," provide date(s), charge(s), military court(s) or authority(ies), and outcome(s). _________________________________________________________________________________________________ SPECIAL QUALIFICATIONS & SKILLS Identify any special licenses you hold (e.g., radio operator): If you know a foreign language, indicate your fluency in each block below(excellent, good, fair) Language Understanding Speaking Reading Writing Do you have any experience with firearms? Yes No MEMBERSHIP IN ORGANIZATIONS (PAST AND PRESENT) Name & Address Type (e.g., social, fraternal, professional) From To Have you ever been an officer or a member of, or made a contribution to, an organization that advocates or practices the commission of acts of or violence to discourage others from exercising their rights under the U.S. Constitution or right granted by law. Yes_______ No_______ PERSONAL DECLARATIONS Do you consume alcoholic beverages? Yes No If “Yes”, how often? _________________ Have you ever used marijuana or hashish? Yes No If yes, when last used? Have you ever used any illegal drug (including a performance-enhancing steroid) not prescribed by a physician? Yes No If yes how often___________ When last used______________ Provide explanation: Have you ever sold or furnished controlled substances or prescription drugs to anyone? Yes No If yes, give details:
PERSONAL-HISTORY-2014-.docx